United States General Accounting Office

GAO Report to the Chairman, Subcommittee

on Health, Committee on Ways and

Means, House of Representatives

April 1996 MEDICARE

Federal Efforts to

Enhance Patient

Quality of Care

G O A

years

1921 - 1996

GAO/HEHS-96-20

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-260737 

April 10, 1996

The Honorable William Thomas

Chairman, Subcommittee on Health

Committee on Ways and Means

United States House of Representatives

Dear Mr. Chairman:

In response to your request, we conducted a study of Medicare efforts to enhance quality of

care for beneficiaries. We found that the Health Care Financing Administration (HCFA) is

modifying its Medicare quality assurance programs to incorporate the latest research on

outcome indicators and current concepts of continuous quality improvement. These changes

are generally consistent with strategies suggested by the experts we interviewed and literature

we reviewed on quality assurance systems. We found, however, that HCFA’s efforts in

distributing comparative performance data lag behind those of state agencies and many

employers in the private sector. Furthermore, GAO’s analysis of HCFA’s previous implementation

efforts raises concerns about how well HCFA will implement comprehensive programs to deal

effectively with poorly performing providers and improve all providers’ performance.

This report was prepared under the direction of David P. Baine, Director, Health Care Delivery

and Quality Issues, and Sandra K. Isaacson, Assistant Director. Other staff contributing to this

report are James Carlan, Assistant Director; Jean Chase, Evaluator; Nancy J. Donovan, Senior

Evaluator; Darrell Rasmussen, Senior Evaluator; and Peter E. Schmidt, Senior Evaluator. If you

have any questions, they can be reached at (202) 512-7101.

We are sending copies of this report to appropriate congressional committees and other

interested parties. We will also make copies available to others upon request.

Sincerely yours,

Carlotta C. Joyner

Associate Director

Health Care Delivery and Quality Issues
Executive Summary 

Purpose

In the past decade, Medicare costs have risen at an average rate of over

10 percent per year. This continued growth has prompted stakeholders to

seek methods to slow down or reduce the cost of services. Because

managed care is viewed as less costly than fee-for-service health care, one

proposal put forth is to expand managed care options for Medicare

beneficiaries. Many are concerned, however, that cost reductions may

result in poor quality of care provided to Medicare beneficiaries.

Currently, the Medicare program reimburses only for care provided in

health maintenance organizations (HMO) and by the fee-for-service sector.

If managed care options are expanded, however, stakeholders want to

ensure that the quality of care furnished to Medicare beneficiaries does

not suffer.

Concerned about ensuring quality in managed care plans that have not

participated in Medicare, the Chairman of the Subcommittee on Health of

the House Committee on Ways and Means requested that GAO (1) discuss

the present and future strategies of the Health Care Financing

Administration (HCFA), which administers the Medicare program, to ensure

that Medicare providers furnish quality health care, in both fee-for-service

and HMO arrangements and (2) obtain experts’ views on desirable

attributes of a quality assurance strategy if more managed care options are

made available to Medicare beneficiaries. In meeting these objectives, GAO

interviewed health care experts and HCFA officials, reviewed quality-related

literature and HCFA documents, and drew on previous GAO work.

Background HCFA oversees programs established to monitor quality of care in the

Medicare program and ensures that corrective action is taken when

problems are found. In 1965, passage of Medicare legislation turned the

federal government into the nation’s single largest payer for health care

and made it responsible for ensuring that beneficiaries receive

good-quality care. This legislation mandated specific programs to help

ensure that medical services purchased on behalf of beneficiaries met

minimum quality standards. Subsequent legislation created a medical

record review program for ensuring that institutional providers meet

minimum standards for delivering appropriate and technically correct

care. Over time, HCFA’s quality assurance programs have changed in

response to shifting utilization patterns created by new Medicare payment

methodologies.

Quality of care is the degree to which health services for individuals and

populations increase the likelihood of desired health outcomes and are

Page 2 GAO/HEHS-96-20 Medicare Quality Assurance
Executive Summary 

Purpose

consistent with current professional knowledge. Most quality assurance

programs used by regulators and providers use performance indicators to

measure whether established standards have been met. Indicators can be

classified according to those that measure (1) structure—the capacity of

an institution, health system, practitioner, or provider to deliver quality

health care; (2) process—physician and other provider activities

performed to deliver the care; and (3) outcomes—the results of physician

and provider activities. Today’s quality assurance strategies focus on

continuous quality improvement, which encourages all providers to

perform better. This differs from past strategies, which tended to focus

more on individual providers’ substandard efforts.

Results in Brief HCFA has two main quality assurance strategies. The first, called

certification, includes (1) the Medicare Provider Certification Program,

under which state agencies or private accrediting bodies assess whether

fee-for-service institutional providers meet certain Medicare standards,

and (2) the HMO Qualification Program, under which HCFA personnel assess

whether HMOs meet similar requirements. The second, called medical

record review, includes the Medicare Peer Review Program, under which

peer review organizations (PRO) evaluate inpatient care and ambulatory

surgery furnished under fee-for-service arrangements or by HMO providers.

GAO has reported serious problems with implementation of these programs

and, in certain cases, with their effectiveness.

When discussing appropriate federal quality assurance strategies, experts

described an approach that (1) builds on existing federal, state, and

private efforts; (2) uses multiple strategies to evaluate care; (3) encourages

continuous quality improvement; and (4) makes information about

providers available to beneficiaries and others in a useful and

understandable way.

HCFA’s recently proposed changes to enhance its quality assurance

program are generally consistent with the strategies recommended by

several health care experts GAO interviewed. HCFA’s new quality assurance

strategy, called the Health Care Quality Improvement Program, builds on

its current programs and parallels private-sector developments. According

to HCFA officials, this program emphasizes cooperation with providers,

continuous quality improvement, development of performance measures,

and improved information about beneficiaries’ satisfaction with the care

they receive in fee-for-service arrangements and HMOs. Unlike some

private-sector purchasers, however, HCFA does not yet provide Medicare

Page 3 GAO/HEHS-96-20 Medicare Quality Assurance
Executive Summary 

Purpose

beneficiaries with health plan-specific information to help them make their

health care purchasing decisions. Furthermore, GAO’s analysis of HCFA’s

previous implementation efforts raises concerns about how well HCFA will

implement comprehensive programs that deal effectively with poorly

performing providers as well as improve all providers’ performance.

Principal Findings

HCFA Has Two Main

Quality Assurance

Strategies

Medicare’s two main quality assurance strategies—certification and

medical record review—are intended to help ensure that Medicare

beneficiaries receive good-quality care. The first, HCFA’s certification

strategy, includes two major programs: the Medicare Provider

Certification Program, directed at fee-for-service institutional health care

providers, and the Medicare HMO Qualification Program, directed at HCFA’s

Medicare HMOs. Both focus on ensuring that providers meet minimum

structural and process requirements. GAO has frequently reported,

however, that HCFA has failed to aggressively enforce the requirements of

these two programs.1

HCFA’s medical review strategy uses PROs to monitor providers’ actions

through reviews of individual medical records to determine patterns of

poor or inappropriate care. If problems are identified, PROs work with

providers to correct the problems and in extreme cases recommend a

monetary penalty or suspension from the Medicare program. GAO

concluded in 1991 and again in 1995 that HCFA had failed to systematically

incorporate the results of PRO review into its HMO monitoring process.2

HCFA’s Quality Assurance

Program Generally

Consistent With Experts’

Views

The experts GAO interviewed suggested four broad strategies for a federal

quality assurance program:

• Build on existing federal, state, and private efforts. These could include

state initiatives, such as those patterned after the National Association of

1

Medicare: Experience Shows Ways to Improve Oversight of Health Maintenance Organizations

(GAO/HRD-88-73, Aug. 17, 1988); Health Care: Actions to Terminate Problem Hospitals From Medicare

Are Inadequate (GAO/HRD-91-54, Sept. 5, 1991); and Medicare: HCFA Needs to Take Stronger Actions

Against HMOs Violating Federal Standards (GAO/HRD-92-11, Nov. 12, 1991).

2

Medicare: PRO Review Does Not Ensure Quality of Care Provided by Risk HMOs (GAO/HRD-91-48,

Mar. 13, 1991) and Medicare: Increased HMO Oversight Could Improve Quality and Access to Care

(GAO/HEHS-95-155, Aug. 3, 1995).

Page 4 GAO/HEHS-96-20 Medicare Quality Assurance
Executive Summary 

Purpose

Insurance Commissioners’ (NAIC) model standards, government

certification, private accreditation, and the use of PROs.

• Use multiple strategies to evaluate care. In addition to accreditation,

experts discussed the use of other performance measures, including

outcome measures and patient satisfaction surveys. Until outcome

measures are more fully developed, however, the experts suggested

continued use of other, more traditional performance measures.

• Encourage continuous quality improvement. Experts believe that

continuous quality improvement programs can identify previously

undetected problems, provide management with constructive feedback,

and help providers and plans to improve their health services.

• Make information about providers available to beneficiaries and others in

a useful and understandable way. Experts stressed that the federal

government should share with beneficiaries information gathered about

quality of care to help beneficiaries in their health care purchasing

decisions.

The experts expressed varying views on implementing these strategies

regarding the most appropriate type of performance data to collect and

who should verify and evaluate the data once collected. Furthermore, they

suggested reexamining federal quality assurance strategies for the entire

spectrum of Medicare providers—from managed care organizations to

fee-for-service providers.

HCFA’s new Health Care Quality Improvement Program is generally

consistent with the four broad strategies cited by the experts GAO

interviewed. HCFA plans to modify its quality assurance strategies to

emphasize outcomes and improvement in the quality of care. This program

will build on HCFA’s current certification and medical record review quality

assurance strategies. For example, HCFA is currently deemphasizing

structure and process measures as the bases for its certification decisions

and is preparing to implement outcome indicators for hospitals, nursing

homes, and other provider types. Additionally, HCFA is reengineering the

entire PRO program to incorporate continuous quality improvement

concepts. PROs will deemphasize individual case review in favor of

cooperative projects with hospitals and HMOs.

HCFA officials are planning a beneficiary satisfaction survey designed to

collect data from Medicare beneficiaries in HMOs. HCFA officials also have

plans to provide Medicare beneficiaries with information to help them

choose providers. The timetable for implementation remains unclear,

Page 5 GAO/HEHS-96-20 Medicare Quality Assurance
Executive Summary 

Purpose

however, because of perceived difficulties in presenting complex

comparative data to consumers in an easily understood way.

Agency Comments HCFA did not agree with GAO’s concerns about how well HCFA will

implement its new quality assurance initiative and its plans for providing

information to beneficiaries. On the basis of GAO’s past studies of HCFA’s

quality assurance implementation efforts, however, GAO remains

concerned about whether HCFA will implement its new comprehensive

program so that it detects and corrects poorly performing providers and

improves all providers’ performance. In addition, GAO believes that some of

the information now being collected by HCFA could be published and

disseminated to Medicare beneficiaries. HCFA also provided specific

technical comments, which we incorporated as appropriate.

Page 6 GAO/HEHS-96-20 Medicare Quality Assurance
Page 7 GAO/HEHS-96-20 Medicare Quality Assurance
Contents

Executive Summary 

Purpose

2

Chapter 1 

Introduction

10

Defining Quality of Care 10

Approaches to Developing Quality Assurance Programs 11

Federal Government’s Role in Ensuring Quality of Care for

Medicare Beneficiaries

12

Objectives, Scope, and Methodology 13

Chapter 2 

HCFA’s Medicare

Quality Assurance

Strategy Is Based on

Compliance With

Standards

14

HCFA’s Certification Strategy Has Separate Programs for

Fee-for-Service and HMOs

14

The Medicare Peer Review Organization (PRO) Program 20

Chapter 3 

HCFA’s New

Strategies Reflect

Experts’ Views on

Appropriate Quality

Assurance

Approaches

23

Experts’ Views About Appropriate Strategies for Medicare

Managed Care Quality Assurance

23

HCFA Is Reinventing Its Certification Program 25

HCFA Is Reengineering the PRO Program 27

Data Standardization Is a Recognized Need 29

HCFA Is Collaborating With Private-Sector Purchasers 29

Beneficiary Satisfaction Information 30

Beneficiary Education Focuses on Personal Health, Not Provider

or Plan Information

31

Chapter 4 

Conclusions and

Agency Comments

33

HCFA Comments and Our Evaluation 33

Appendixes Appendix I: Comments From the Department of Health and

Human Services

38

Appendix II: Experts Interviewed 41

Appendix III: Accrediting Organizations 44

Page 8 GAO/HEHS-96-20 Medicare Quality Assurance
Contents

Related GAO Products 48

Tables Table III.1: Organizations Whose Accreditation HCFA Deems to

Be Adequate Assurance That Providers Meet HCFA Conditions of

Participation

44

Table III.2: Organizations That Accredit Institutional Health Care

Providers or Units Within Providers

45

Abbreviations

AHCPR Agency for Health Care Policy and Research

AOA American Osteopathic Association

DRG diagnosis related group

HCFA Health Care Financing Administration

HEDIS Health Plan Employer Data and Information Set

HHS U.S. Department of Health and Human Services

HMO health maintenance organization

NAIC National Association of Insurance Commissioners

NCQA National Committee for Quality Assurance

OBRA Omnibus Budget Reconciliation Act

PPO preferred provider organization

PRO peer review organization

RTI Research Triangle Institute

Page 9 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 1 

Introduction

In the past decade, Medicare costs have risen at an average rate of over 10

percent per year. Medicare program benefit payments have increased from

$69.5 billion in 1985 to an estimated $180 billion in 1995,3

 prompting the

Congress and others to search for ways to reduce the program’s rate of

growth. One proposal put forth is to increase the managed care choices of

Medicare beneficiaries who may be considering enrolling in a managed

care plan.4

 Although stakeholders believe that managed care organizations

can furnish needed services to beneficiaries at less cost than

fee-for-service arrangements, they are concerned about ensuring that

those beneficiaries who enroll receive high-quality care.5

Defining Quality of

Care

According to the Institute of Medicine, quality of care is defined as “the

degree to which health services for individuals and populations increase

the likelihood of desired health outcomes and are consistent with current

professional knowledge.”6

 To evaluate whether quality of care is being

provided to those individuals and populations, one or more of the

following attributes usually are measured:

• appropriateness (patients receive the right care at the right time),

• technical excellence (providers furnish care in the correct way),

• accessibility (patients obtain care when needed), and

• acceptability (patients are satisfied with their care).

These attributes can be assessed by regulators, providers, or others using

performance indicators that measure organizational structures, provider

actions, and the results of care. Structure indicators measure the capacity

of an institution, health system, practitioner, or provider to deliver quality

health care. Having a safe and clean facility and a quality assurance

program in place in an organization are examples of structure indicators.

Process indicators measure what a provider does to and for the patient.

Identifying and evaluating what diagnostic tests a physician performs

when examining a patient with chest pain is an example of a process

3

Estimate is for fiscal year. Amounts are not adjusted for inflation.

4

Currently, Medicare pays only for health care furnished by providers working on a fee-for-service

basis or within a health maintenance organization (HMO) or hospice.

5

Medicare also contracts with organizations meeting the statutory definition of a competitive medical

plan. Because these organizations are in most respects similar to HMOs, in this report we use the term

“HMO” to cover both. In addition, HCFA contracts on a reasonable cost basis with the organizations

called Health Care Prepayment Plans, which cover only Medicare part B services.

6

Institute of Medicine, Medicare: A Strategy for Quality Assurance, Kathleen Lohr, ed. (Washington,

D.C.: National Academy Press, 1990).

Page 10 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 1 

Introduction

indicator. Outcome indicators measure the results of providers’ actions

and are viewed as the most direct measure of the quality of care furnished

because they represent the providers’ success. Examples of outcome

indicators are mortality, complications resulting from surgery, patient

satisfaction with the care received, and functional status.7

Approaches to

Developing Quality

Assurance Programs

Assessing quality of care involves reaching consensus about standards and

developing reliable and valid structure, process, and outcome measures. If

the standards are not met, then providers and regulators must develop

approaches to make it more likely that health care is furnished in ways

that meet the standards.

In the past, quality assurance programs focused on the care provided to

individual patients. These programs tended to direct improvement

activities toward individual providers identified as responsible for

mistakes rather than encourage improvement in overall health care

delivery. As a result, quality assurance efforts focused on a few providers,

and the effects of these efforts were limited to a small percentage of the

population. Furthermore, these programs often resulted in adversarial

relations between the reviewers and those being reviewed. In recent years,

approaches to quality assurance have begun to focus on continuous

quality improvement. Under this approach, attempts are made to identify

and establish excellent care by focusing attention on inappropriate

variation in the quality of care furnished to identified populations and

eliminating the variations. This approach strives to make everyone’s

performance better, regardless of prior performance. Other recent

approaches to quality assurance have also included initiatives for

collecting and disseminating information on performance measures. The

Health Plan Employer Data and Information Set (HEDIS) is a major attempt

to advance the collection of information on quality of care indicators.8

HEDIS indicators of health plan activities in five performance areas have

been adopted by many large health care purchasers and some regulators

to gauge the quality of care provided by health plans.9

 Attempts to advance

the dissemination of HEDIS and other information on quality of care include

the publication of “report cards” by health plans intended to describe their

7

Functional status is the extent to which people can perform activities of daily living and their basic

social roles.

8

Initial development efforts were organized by The HMO Group, a coalition of group and staff HMOs.

Subsequent revision of these measures has occurred under the auspices of the National Committee on

Quality Assurance (NCQA).

9

The five performance areas are quality, access and patient satisfaction, membership and utilization,

finance, and health plan management.

Page 11 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 1 

Introduction

performance measured against selected performance indicators.

Employers are also providing quality of care performance information to

their employees about health plans with which they contract. For

example, the California Retirement System recently distributed a report

containing both performance indicators about quality and member

satisfaction survey results.10

Federal Government’s

Role in Ensuring

Quality of Care for

Medicare

Beneficiaries

HCFA oversees programs established to monitor quality of care in the

Medicare program and ensures that corrective action is taken when

problems are found. In 1965, passage of federal Medicare legislation

turned the federal government into the nation’s single largest payer for

health care and made it responsible for ensuring that beneficiaries receive

good-quality care.11 This legislation mandated that the government

establish specific programs to help ensure that medical services purchased

on behalf of beneficiaries meet minimum quality standards. Over time,

these programs have changed in response to shifting utilization patterns

created by new Medicare payment methodologies.

Initially, the mandated quality assurance programs focused on setting

minimum structural standards for hospitals and other institutional

providers to ensure that they could deliver care of acceptable quality. In

1986, in response to changes in hospital care delivery systems, HCFA

modified its hospital certification program to include more process

measures. Also, when the Medicare program began to contract with HMOs,

structural standards to help ensure the capacity of HMOs to deliver care

were established. Subsequent legislation created a medical record review

program for ensuring that institutional providers meet minimum standards

for delivering appropriate and technically correct care. This program,

however, tended to focus more on utilization of medical services rather

than the quality with which they were delivered.

As a result of hospital and HMO reimbursement changes in the early 1980s

intended to control rising Medicare costs, hospitals had the perverse

incentive to admit patients unnecessarily and discharge them prematurely.

Also, hospitals and HMOs had an incentive to skimp on costly care. To

counter these incentives, the Congress redesigned the Medicare medical

10In our report, Health Care: Employers and Individual Consumers Want Additional Information on

Quality (GAO/HEHS-95-201, Sept. 29, 1995), we discuss in more detail the kind of information

employers and individual consumers find useful and the kinds of information they want in the future.

11The Social Security Amendments of 1965 (P.L. 89-97).

Page 12 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 1 

Introduction

record review program to focus on detecting unnecessary hospital

admissions and substandard care and by mandating the inclusion of HMOs.

In overseeing the quality of care furnished by Medicare providers, HCFA has

a range of ways to address providers’ failure to meet established

standards. Usually HCFA begins by requiring that providers take timely

corrective action to address the identified deficiencies. Ultimately, the

agency has the authority to suspend Medicare payment to substandard

providers.

Objectives, Scope,

and Methodology

In April 1995, the Chairman of the Subcommittee on Health of the House

Committee on Ways and Means asked us to examine ways to best ensure

that professional, quality health care would be furnished across a broad

spectrum of health plans. Currently, HCFA reimburses for care provided

only by the fee-for-service sector or by HMOs. The Chairman requested that

we (1) discuss HCFA’s present and future strategies to ensure that Medicare

providers furnish quality health care in both fee-for-service and HMO

arrangements and (2) obtain experts’ views on desirable attributes of a

quality assurance strategy if more managed care options are made

available to Medicare beneficiaries.

To analyze HCFA’s present and future plans, we reviewed documents on

HCFA’s efforts and plans, conducted interviews with HCFA officials, and

drew on previous GAO reports. To obtain the views of experts, we

conducted over 30 structured interviews with experts selected to

represent a wide range of perspectives, including those of health plans,

health care researchers, federal and state agencies, major purchasers of

health care, and accrediting agencies. (See app. II for a list of the experts

we interviewed and their affiliations.) We also reviewed literature about

measuring the quality of health care, articles about major health care

purchasers’ initiatives, and previous GAO reports on measuring provider

performance. We presented initial findings from our work in testimony

before the Subcommittee on July 27, 1995.12

Our work was performed between April and December of 1995 in

accordance with generally accepted government auditing standards.

12Medicare: Enhancing Health Care Quality Assurance (GAO/T-HEHS-95-224, July 27, 1995).

Page 13 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 2 

HCFA’s Medicare Quality Assurance Strategy

Is Based on Compliance With Standards

Since its inception, Medicare has had two major quality assurance

strategies to ensure that beneficiaries receive quality care. Until recently,

these strategies were based on a regulatory approach—setting minimum

standards for health care organizations and implementing systems to

identify and discipline substandard providers. HCFA’s two strategies cover

both fee-for-service providers and HMOs. The first, certification, is intended

to ensure that minimum structural requirements, such as appropriate

staffing and minimum process requirements (for example, an infection

control system that identifies and corrects problems), exist to allow for

quality care. The second, review of beneficiary medical records, is

intended to ensure that the processes of care reflect the current best

practices in the community. HCFA, however, has not always fully used

available information in its monitoring programs nor acted effectively

when significant problems were found. As a result, HCFA cannot ensure

that Medicare beneficiaries are receiving quality care.

HCFA’s Certification

Strategy Has Separate

Programs for

Fee-for-Service and

HMOs

HCFA’s certification strategy includes two major programs. The Medicare

Provider Certification Program, in existence since Medicare’s inception in

1965, is directed at ensuring that fee-for-service institutional health care

providers serving Medicare beneficiaries meet minimum health and safety

requirements. The other program, HCFA’s Medicare HMO Qualification

Program, dates to the origin of the Medicare HMO contracting program in

the Social Security Amendments of 1972. This program was established to

ensure that HMOs with contracts to serve Medicare beneficiaries meet

minimum financial and structural standards.

The Medicare Provider

Certification Program

Assesses Fee-for-Service

Institutional Providers

Medicare law requires institutional providers of care, such as hospitals and

nursing homes receiving direct fee-for-service Medicare payments, to

comply with certain physical and organizational requirements. These

requirements are usually called conditions of participation.13 Conditions of

participation identify minimum standards that policymakers thought were

necessary to be met for quality health care to occur. In the past, the

conditions related almost exclusively to structural quality of care

indicators. This remains largely true for hospitals, although a 1986 revision

13Other types of providers covered by this program include psychiatric hospitals, home health

agencies, clinics, and rehabilitation agencies. Certain more specialized providers, such as organ

procurement organizations, suppliers of portable X-ray services, and physical therapists in

independent practice providing outpatient physical therapy services must meet conditions of coverage

similar to conditions of participation to receive Medicare reimbursement. Conditions of participation

for long-term care facilities, significantly altered by the Congress in 1987, are now termed

“requirements.”

Page 14 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 2 

HCFA’s Medicare Quality Assurance

Strategy Is Based on Compliance With

Standards

added some process indicators.14 A full-service community hospital must

meet 20 conditions of participation regarding such matters as the

hospital’s governing body, physical plant, clinical and emergency services,

nursing service, and food service. Each condition is subdivided into

multiple standards, most of which must be met if an institution is to

comply with the condition. Surveyors who review the hospital to

determine its compliance with the conditions have usually only

determined whether the institution has established the necessary policies

and procedures to meet the conditions of participation. Federal

regulations and survey procedures do not require surveyors to determine

what actual patient outcomes have been.15

In the mid-1980s, HCFA officials began to work toward modifying

conditions of participation for other types of institutions to focus the

conditions more toward beneficiary outcomes. According to the officials,

this process began in 1986 with modification of the survey process for

nursing homes to emphasize review of patient outcomes and the provision

of patient care services. HCFA implemented major revisions of the

conditions of participation for home health agencies and nursing homes in

1991 and 1992, respectively.16 Finally, in April of 1995, HCFA implemented

new outcome-oriented survey procedures for renal dialysis facilities.

Certification surveys intended to determine whether an institution is in

compliance with the conditions are performed by either state agencies or

private accrediting organizations. HCFA contracts directly with state

agencies to perform certification surveys of some institutional providers.

However, HCFA deems a hospital’s or home health agency’s accreditation

by a designated private accrediting organization to be adequate assurance

that the provider meets the conditions of participation.17 If a hospital or

home health agency does not request accreditation from such an

accrediting organization, the state agency where the institution is located

will perform the certification survey.

14HCFA is revising hospital conditions of participation to reorient them toward patient outcomes. See

chapter 3.

15HCFA is changing its certification requirements to a more outcome-oriented approach. HCFA’s plans

are discussed in detail in chapter 3.

16See chapter 3 for a more extensive discussion of the new conditions of participation for nursing

homes.

17HCFA is considering extending deeming authority to private organizations that accredit ambulatory

surgical centers.

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Chapter 2 

HCFA’s Medicare Quality Assurance

Strategy Is Based on Compliance With

Standards

When deciding whether to grant a private accrediting organization

deeming status, HCFA reviews the policies of the accrediting organization

to determine that the organization, among other things,

• has accreditation requirements that are at least equivalent to Medicare

certification requirements;

• has survey teams and procedures adequate to detect problems, ensure

corrective action, and meet Medicare requirements for the frequency and

prior announcement of visits; and

• is willing to provide HCFA with a copy of the most current accreditation

survey and any other information on the survey, including corrective

action plans, that HCFA may require.

HCFA grants private accrediting agencies deeming authority for a 6-year

period.18 (app. III lists the organizations whose accreditation is deemed

equivalent to HCFA certification; it also lists other organizations that

accredit institutional health care providers or units within providers.)

Regardless of whether HCFA or state agency personnel perform the review,

the process used to determine whether an institution meets certification

requirements involves an on-site survey19 by a team of registered nurses

and persons trained in other health-related disciplines. This survey may

take several days depending on the type and size of provider. The survey

includes a thorough review of the provider’s policies, procedures, and

systems. At the conclusion of the inspection, the team meets with

appropriate provider officials and informs them of its findings.

Subsequently, the team prepares a formal written report and sends it to

the provider. If the team finds that the provider does not comply with one

or more conditions of participation, it will ask the provider to submit a

corrective action plan, including a timetable. At the end of the time period

specified in the plan’s timetable, the surveying agency may perform a

limited resurvey to ensure that all identified problems have been

corrected, or it may require the provider to submit documentation that

corrective action has occurred.

If the provider does not comply with conditions by the end of the time

period in the plan’s timetable, or if the problem was severe enough to

seriously endanger Medicare beneficiaries, HCFA may revoke the provider’s

18The Joint Commission’s deeming authority for hospitals is specified by statute and has no time limit.

19Hospitals accredited by the Joint Commission are surveyed every 3 years. Nursing homes and home

health agencies must by law be surveyed annually. According to HCFA, because of budgetary

constraints, other types of providers are surveyed less frequently.

Page 16 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 2 

HCFA’s Medicare Quality Assurance

Strategy Is Based on Compliance With

Standards

certification to receive Medicare payment. In our 1991 review of the

Medicare hospital certification program, however, we found that HCFA

rarely terminated hospitals from the Medicare program even though they

might have been out of compliance with Medicare requirements months

longer than anticipated or allowed by regulation. This situation occurred

because federal and state officials preferred to work with substandard

hospitals to bring them into compliance, political pressures were exerted

to keep them open if possible, and quality problems less obvious than

gross negligence were difficult to document. This apparent unwillingness

to terminate noncompliant hospitals has cast some doubt on HCFA’s

willingness to act against any but the very worst hospitals.20 While

terminating hospitals from Medicare is usually undesirable except as a last

resort, we reported that HCFA should terminate facilities that are

persistently noncompliant with conditions of participation.

To ensure that state agencies and private accrediting organizations are

performing their surveys adequately, HCFA performs validation surveys.

HCFA personnel conduct validation surveys on a small percentage of the

facilities surveyed by state agencies; in addition, HCFA contracts with state

agencies to conduct validation surveys of the facilities surveyed by private

accreditors. In 1993, state agency personnel performed 181 validation

surveys among the approximately 5,200 hospitals accredited by the Joint

Commission. The 1993 HCFA annual report on validation surveys of

hospitals accredited by the Joint Commission concluded that a decline

over several years in the percentage of hospitals found by the validation

surveys to have general health and safety deficiencies provided increased

assurance that accredited hospitals met federal standards. However, some

problems continued with the Joint Commission’s enforcement of the Life

Safety Code.21 In 1994, HCFA personnel performed 863 validation surveys

among 15,493 nursing homes surveyed by state agencies. HCFA officials told

us that the results of HCFA’s monitoring program for state survey agencies

indicate that state agency performance of nursing home reviews is in some

cases uneven. However, they said that they had assessed the problem and

were now working with state agencies to help them improve through

problem identification, consultation, and training.

20Health Care (GAO/HRD-91-54, Sept. 5, 1991).

21The Life Safety Code is a consensus standard adopted by the National Fire Protection Association

and incorporated by reference into the conditions of participation.

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The Medicare HMO

Qualification Program

HMOs wanting to provide health care services to Medicare beneficiaries on

a risk or cost basis must have a contract with the Medicare program.22

Under HCFA’s Medicare HMO Qualification Program, HCFA personnel visit

HMOs with cost or risk contracts at least once every 2 years to monitor

their compliance with Medicare requirements.23 The site visits are similar

to those used in the Medicare Provider Certification Program. HCFA

personnel spend several days at the HMO comparing the HMO’s policies and

procedures with Medicare requirements. The monitoring team informs the

HMO of its preliminary findings at the end of the visit and later prepares a

formal report. If the HMO has failed to meet one or more requirements, it

must submit a corrective action plan, including a timetable for correcting

the deficiency. HCFA may revisit the site to monitor compliance at the end

of the time period specified in the plan’s timetable, or it may simply

require regular progress reports. If the HMO fails to correct the deficiency

in a timely manner, HCFA may terminate the HMO’s Medicare contract or,

under some circumstances, impose a civil monetary penalty or suspend

Medicare enrollment.

Inadequate Enforcement of

Medicare HMO Quality

Assurance Requirements

We have criticized HCFA for failing to aggressively enforce Medicare quality

assurance requirements for HMOs. In 1988 and again in 1991, we found that

HCFA’s efforts to obtain corrective action from a few noncompliant HMOs

were largely ineffective even though HCFA repeatedly requested such

action.24 Furthermore, HCFA often found that the same problems existed

when it made its next annual monitoring visit.25 We found the same

problems again in an August 1995 report.26 We concluded that HCFA’s

Qualification Program is inadequate to ensure that Medicare HMOs comply

22HMOs that have a risk contract with HCFA are paid a fixed amount for each enrolled beneficiary

based on the average Medicare costs for all beneficiaries in the HMOs’ service area. Cost HMOs are

paid by HCFA a predetermined monthly amount per beneficiary based on a total estimated budget.

These payments are retrospectively adjusted on the basis of the HMO’s report of its incurred costs.

HMOs may also opt to be reimbursed on a fee-for-service basis. In this case, they are not subject to the

Medicare HMO qualification process.

23In this report, the term “HMO Qualification Program” refers to HCFA’s program for ensuring that

HMOs meet all Medicare requirements. Some of these are contained in title 13 of the Public Health

Service Act and others in title 18 of the Social Security Act. This term may also be used to refer to the

process of ensuring that HMOs meet the requirements for federal qualification contained in title 13

above. HCFA has announced that it will perform site visits at all HMOs annually, beginning in fiscal

year 1996. HCFA does not accept private organization accreditation or state agency certification as

evidence that an HMO meets federal standards.

24Medicare (GAO/HRD-88-73, Aug. 17, 1988) and Medicare (GAO/HRD-92-11, Nov. 12, 1991).

25Although HCFA normally performed HMO monitoring visits every 2 years, it often increased the

frequency to annually for HMOs with serious problems.

26Medicare (GAO/HEHS-95-155, Aug. 3, 1995).

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with standards for ensuring quality of care. Specifically, this program

remains inadequate for four main reasons:

• HCFA does not determine if HMO quality assurance programs are operating

effectively. HCFA’s routine compliance monitoring reviews do not go far

enough to verify that HMOs monitor and control quality of care as federal

standards require. The reviews check only that HMOs have procedures and

staff capable of quality assurance and utilization management—not for

effective operation of these processes.

• HCFA does not systematically incorporate the results of PRO review of HMOs

or use PRO staff expertise in its compliance monitoring.27 A routine HCFA

site visit to an HMO generally involves about three people without

specialized clinical or quality assurance training, who spend a week or less

focused largely on Medicare requirements for administration,

management, and beneficiary services rather than on medical quality

assurance. About a third of staff time is typically spent on quality-related

matters. PRO staff generally have the specialized clinical training needed to

perform quality assurance reviews.

• HCFA does not routinely collect utilization data that could most directly

indicate potential quality problems. In the fee-for-service sector, claims

data are available and can be used to detect potential overutilization of

services. Although HCFA has the authority to require HMOs to collect such

data and federal standards require that HMOs have information systems to

report utilization data and management systems to monitor utilization of

services, no comparable data exist for use in the Medicare HMO

Qualification Program to detect potential underutilization. As a result,

even such basic information as hospitalization rates; the use of home

health care; or the number of people receiving preventive services, such as

mammograms, is unknown.

• HCFA does not evaluate HMO risk-sharing arrangements with providers. The

agency does not routinely assess whether HMO risk-sharing arrangements

create a significant incentive to underserve, although in the Omnibus

Reconciliation Act (OBRA) of 1990, the Congress gave the Department of

Health and Human Services (HHS) authority to limit arrangements that it

found provided an excessive incentive to underserve. As of March 15,

1996, the Department had not yet issued final regulations on methods for

gauging how much risk an HMO can legitimately pass to providers and

27Although HCFA’s 1995 HMO monitoring protocol covers PRO reviews, it does so in the context of

ensuring that the HMO cooperates with the PRO review process and incorporates the results of the

review into the HMO’s own quality assurance process. We are advocating that HCFA incorporate the

results of PRO reviews into HCFA’s HMO Qualification Program in a systematic way. For example,

PRO findings might be used as one basis for evaluating the effectiveness of the HMO’s quality

assurance system.

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requirements that providers must meet to accept such risk. However, a

HCFA official told us that HCFA expected to publish these regulations

shortly.

We also found that enforcement processes remain slow when HCFA does

find quality problems or other deficiencies at HMOs that do not comply

promptly with federal standards. For example, between 1987 and 1994,

HCFA repeatedly found that a Florida HMO did not meet Medicare quality

assurance standards and received PRO reports indicating that the HMO was

providing substandard care to a significant number of beneficiaries.

During this period, it permitted the HMO to operate as freely as a fully

compliant HMO.

28 We also found that HCFA does not routinely release its site

visit reports to the public.29 Consequently, when an HMO is found to violate

federal standards, Medicare beneficiaries may not know of quality

problems that might influence their decision to join or remain enrolled in

that HMO.

The Medicare Peer

Review Organization

(PRO) Program

HCFA’s medical record review strategy, implemented through the Medicare

PRO program, was designed to identify providers whose care does not meet

recognized medical standards. PROs generally have been required to focus

their reviews on care furnished to beneficiaries on a fee-for-service basis

in hospitals and outpatient surgical centers and care furnished by HMOs.

Although HCFA may use the PRO program to review care provided to

beneficiaries in other settings such as physicians’ offices, it has chosen not

to use this authority because reviewing care at all private U.S. physicians’

offices would be overwhelming.

Until recently, the PROs’ primary review method was to monitor providers’

actions through reviews of individual medical records. A number of

sampling strategies have been used to select records for review. The

prevailing strategy in the fee-for-service sector has been to draw a random

sample only from Medicare hospital admissions. However, other samples

drawn from hospital admissions have focused on areas perceived to be at

high risk, for example, cases in which potentially adverse events such as

hospital readmission within 31 days of a discharge have occurred. In the

HMO sector, the PROs drew a random sample of enrolled beneficiaries, both

living and recently deceased, and asked the HMOs to determine which of

these sampled beneficiaries had received either ambulatory or inpatient

services during the period in question. For these beneficiaries, the PRO

28On July 5, 1995, HCFA declared the HMO in compliance with requirements.

29The public may obtain these reports under the Freedom of Information Act.

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reviewed the medical records for all care furnished by the HMO over a

12-month period in both ambulatory and inpatient settings.

PRO medical review usually begins when a reviewer employed by the PRO

reviews the selected medical record.30 If a problem is found, the medical

record is referred to a PRO physician. If the PRO physician believes that a

quality concern might exist, the PRO writes to the providers responsible for

the patient’s care and gives them the opportunity to provide an

explanation for the potential concern. Then, if the concern is not resolved,

it is referred for further review to a physician who is a specialist in the

type of care being questioned. If a provider demonstrates a pattern of

confirmed problems, the cases are sent to the PRO’s medical review

committee, composed mainly of physicians, which determines whether a

corrective action plan is necessary to prevent similar problems from

occurring in the future.31 If the provider will not or cannot correct the

identified poor practice, the PRO may recommend that the HHS Office of

Inspector General impose a sanction. Possible sanctions include

suspension of eligibility to receive reimbursement from the Medicare

program for a specified period or monetary penalties.

The PRO program has been criticized by providers and other health care

experts because of the adversarial role some experts believe the PROs have

taken. Furthermore, relatively few substandard providers have been

identified as a result of this approach. The medical review model used by

the PROs focused on the detection and correction of individual aberrant

providers. HCFA officials found this particular model to be confrontational,

unpopular with the physician community, and of limited effectiveness.

In the past, we have also been critical of HCFA’s use of the PRO program to

monitor HMOs. In a 1991 report, we cited several problems with the PROs’

ability to monitor care provided by HMOs with risk contracts.32 First,

although HCFA contracted with PROs to perform an initial review of the

adequacy of risk HMO quality assurance plans in 1987, HCFA failed to require

HMOs to submit their plans for review. Furthermore, when the PROs found

deficiencies in HMO quality assurance plans, HCFA did not require HMOs to

correct them. As a result, HCFA could not be assured that HMOs were

identifying and correcting quality of care problems. In commenting on this

30PRO reviewers are usually nurses or other medical professionals.

31However, if the care in question is so poor as to constitute a gross and flagrant violation of the

provider’s duty to provide good care, it is sent immediately to the medical review committee, which

determines if the PRO should recommend a sanction to the HHS Office of Inspector General.

32Medicare (GAO/HRD-91-48, Mar. 13, 1991).

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report, HCFA stated that in 1987 it did not believe that PROs had the

expertise to perform reviews of HMOs’ quality assurance plans. However,

HCFA now believes the situation may have changed. HCFA is currently

studying the possibility that PROs could play an active role in monitoring

Medicare HMO’s quality assurance systems. Second, HCFA did not require

risk HMOs to submit patient encounter data to HCFA. As a result, HCFA

lacked adequate HMO utilization data and other patient information that

PROs could use to serve as the basis for sampling HMO beneficiaries

receiving hospital care or to identify statistical patterns of care that may

suggest underutilization or inappropriate care. Finally, HCFA failed to

incorporate the results of PRO review into its HMO qualification monitoring

process. As a result, HCFA could not be assured that high-quality health

care was being provided to Medicare beneficiaries in risk HMOs. This

failure was still an issue when we reviewed HCFA’s oversight of HMOs

serving Medicare beneficiaries in 1995.

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HCFA is substantially revising its quality assurance strategy to reflect

state-of-the-art quality assurance practices, such as continuous quality

improvement, outcomes measurement and dissemination of performance

results, that health care professionals believe will more effectively

improve quality of care. HCFA’s new strategy, called the Health Care Quality

Improvement Program, is founded on the premise that HCFA should try to

buy the best care possible for Medicare beneficiaries and is generally

consistent with many of the elements of appropriate quality assurance

strategies cited by the health care experts we interviewed. As a result,

HCFA officials believe that they will be able to improve the overall quality of

care for all Medicare beneficiaries.

HCFA, however, is just now developing plans to provide additional

information to beneficiaries about plans’ performances. We believe that

this change is needed as HCFA revises its quality assurance strategy. The

experts we interviewed believe that providing information to help

beneficiaries make sound purchasing decisions is essential to a good

quality assurance program.

Experts’ Views About

Appropriate Strategies

for Medicare Managed

Care Quality

Assurance

When we asked the experts about their views on ensuring that quality care

is provided to Medicare beneficiaries through a variety of managed care

arrangements, they cited the following characteristics for a federal quality

assurance strategy:

• The strategy should build on existing federal, state, and private efforts.

These efforts could include state initiatives such as those built on National

Association of Insurance Commissioners’ (NAIC) quality assurance and

other model standards,33 as well as existing private and federal systems,

such as government certification and private accreditation programs, and

the long-standing involvement and experience of PROs in collecting and

evaluating quality assurance data.

• The strategy should use many measures to evaluate care. In addition to the

ongoing quality assurance activities already discussed, steps should be

taken to develop valid and reliable performance measures, including

33NAIC is a voluntary association consisting of the heads of the insurance departments of the 50 states,

the District of Columbia, and four U.S. territories. Over the years, NAIC has developed about 200

model laws, regulations, and guidelines setting out the legal and regulatory authorities it believes are

necessary to effectively regulate insurance. The responsibility for requiring states to adopt or

implement NAIC’s model policies falls to state legislatures. Recently, NAIC established a work group

to develop health plan accountability standards in the areas of provider credentialing, utilization

management, quality assessment and improvement, data reporting, grievance procedures, managed

care network adequacy and contracting, accessibility, and confidentiality. NAIC also is undertaking the

task of consolidating its regulations by drafting a model uniform licensing act to cover all health

insurers.

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patient satisfaction surveys, in evaluating health care providers’

performance. The experts stressed the importance of outcome

performance measures, recognizing that these measures are not yet fully

developed. Therefore, they suggested that other, more traditional,

performance measures be used until consensus is reached on appropriate

outcome measures. Patient satisfaction surveys are becoming increasingly

popular and important as a performance measurement tool. Like large

private-sector health care purchasers, the federal government could

employ this strategy as one tool to measure provider performance.34

• The strategy should encourage continuous quality improvement. Experts

view encouraging providers’ continuous quality improvement activities as

an important role for the federal government. In this regard, they

recognized the importance of external oversight programs designed to

ensure that providers are continually assessing and improving the care

they furnish. Such oversight programs are an important tool for identifying

previously undetected problems, providing management with constructive

feedback, and assisting providers and plans to improve their health

services.35

• The strategy should make information about providers available to

beneficiaries and others in a useful and understandable way. A common

theme expressed by the experts we interviewed was the need to provide

understandable and reliable data on managed care organizations to

beneficiaries to help them in their health care purchasing decisions.

Several told us that this information should be disseminated at the

regional or local level because beneficiaries derive little benefit from

national data.

Although the experts we interviewed agreed on the broad strategies

needed for a comprehensive Medicare quality assurance program, they

were less unanimous in their views on implementing these strategies. For

example, they expressed varying views on the most appropriate

performance data to collect, who should verify these data, and who should

be responsible for evaluating the data once they are collected and verified.

Finally, experts expressed the view that federal quality assurance

34The Agency for Health Care Policy and Research (AHCPR), through a contract with Research

Triangle Institute (RTI), has designed a survey to collect information on consumers’ attitudes about

access to health care, use of specific services, perceptions about health outcomes and quality of care,

and satisfaction with care. In addition, AHCPR awarded 5-year cooperative agreements to three

consortia led by RTI, RAND, and Harvard Medical School to further develop the knowledge base of

consumer surveys and provide consumers, and purchasers acting on their behalf, with valid, reliable,

relevant information for selecting health insurance plans.

35For example, the Maine Medical Assessment Foundation gathers data about the volume of specific

services provided by physicians in different parts of the state and then supplies this information to

Maine physicians. According to the 1994 Physician Payment Review Committee’s Annual Report to

Congress, Maine’s system has resulted in fewer back surgeries and hysterectomies.

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strategies should be reexamined and enhanced for the entire spectrum of

Medicare providers—that is, managed care organizations and

fee-for-service providers.

HCFA Is Reinventing

Its Certification

Program

As part of its Health Care Quality Improvement Program, HCFA intends to

reinvent the Medicare Provider Certification Program. According to a HCFA

official, as outcome indicators become more valid, reliable, and accepted

by providers, outcome indicators will replace current structure indicators

in the certification process. Currently, HCFA is using outcome measures as

the basis for its nursing home certification decisions. Furthermore, HCFA is

collecting data from home health agencies to construct outcome

measures. HCFA is also developing outcome-oriented conditions of

participation for hospitals, which may be implemented in 1997.

HCFA’s Nursing Home

Outcome Measures

In 1987, the Congress passed legislation that extensively revised the

Medicare conditions of participation for skilled nursing facilities.36 These

new conditions, renamed requirements, as implemented by HCFA require a

resident-centered survey emphasizing review of the outcomes of the care

actually furnished. This review is in addition to the review of the nursing

home’s performance in relation to specific structure and outcome

indicators.

The resident-centered survey requirement is based upon the selection of a

case mix-stratified sample of residents performed in two phases. During

the first phase, about 60 percent of the whole sample is selected. Included

are residents who have special needs such as those requiring considerable

assistance with activities of daily living, those who cannot be interviewed,

and those who fit into the specific area of focus selected for the survey. In

addition, the sample should include some residents who (1) are new

admissions; (2) are at high risk of neglect and abuse because they have

dementia, few visitors, or are bedfast; (3) have difficulty communicating;

(4) are receiving hospice services; or (5) have other special circumstances.

After the survey team has gained enough experience at the facility to

identify other areas of special concern, the remaining 40 percent of the

survey sample is selected, focusing on patients in these areas. The

surveyors interview each of the selected residents and then review their

medical records to determine if the patient’s needs have been properly

36Sections 4201(a)(3), 4202(a)(2), and 4203(a)(2) of OBRA 1987 (P.L. 100-203). HCFA regulations

implementing this statutory change were effective in 1992.

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assessed, appropriate interventions have been implemented, and the

patient has been evaluated to determine the intervention’s effect.

Also as a result of the 1987 legislation, on July 1, 1995, HCFA implemented

the Long Term Care Enforcement Regulation, a new set of intermediate

sanctions for the nursing home certification process. These give HCFA and

the state agencies a broad range of remedies for noncompliance with

requirements short of termination from the program. These remedies

range from such measures as enhanced state monitoring and directed

in-service training to civil monetary penalties, temporary takeover of the

facility’s management, and denial of payment for new admissions or even

all residents. HCFA officials told us that they provided extensive training in

the new procedures and remedies to state agency personnel.

HCFA is also developing a set of nursing home outcome indicators such as

the prevalence of decubitus ulcers and percentage of patients whose

capability for activities of daily living has declined over a 3-month period.

These indicators, now being measured in a five-state demonstration

project, stem from an expanded version of the minimum data set

mandated by law for use in all nursing facilities.37 HCFA eventually hopes to

use the results of these indicators to permit state agencies to focus

increased resources on nursing homes showing poor performance by

decreasing the frequency of surveys for those nursing homes with good

performance. HCFA officials also hope that the nursing homes will use the

data for continuous quality improvement activities.

HCFA Is Developing

Outcome Indicators for

Other Health Care Settings

HCFA is also preparing new, outcome-oriented conditions of participation

for home health agencies, hospitals, and dialysis facilities to be followed

by new requirements for hospices. In conjunction with the new home

health agency conditions of participation, HCFA is developing indicators

that reflect changes in beneficiaries’ functional and health status.

Examples of such indicators are (1) percentage of patients showing

improvement in walking and (2) percentage of patients readmitted to an

acute care hospital. As with nursing homes, HCFA officials hope to use

these indicators to determine the frequency with which different home

37The nursing home minimum data set was mandated by OBRA 1987. It contains the minimum

assessment data items needed to comprehensively and continuously evaluate the condition of a

nursing home resident. These include information on the resident’s cognitive status, communication

and vision patterns, mood and behavior, and activity patterns, as well as more clinically oriented

information such as data on mobility, decubitus ulcers and other skin problems, disease signs and

symptoms, and nutritional status. The data set is intended to be used both as a tool for planning the

care of individual residents, quality monitoring, and payment classification systems.

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health agencies should be reviewed. They also hope that the agencies will

use the indicators for continuous quality improvement projects.

Additionally, HCFA is working with the Joint Commission, hospital

associations, and others to draft new, outcome-oriented hospital

conditions of participation. HCFA officials told us that they hope to publish

these new conditions in the Federal Register for public comment in 1996

and implement them during 1997.

HCFA is also working with the Joint Commission and the American

Osteopathic Association (AOA) to modify its process for validating these

organizations’ accreditation surveys. The new process calls for HCFA to

conduct a more comprehensive evaluation of these organizations’ hospital

accreditation programs, including standard setting, training surveyors,

conducting the survey, enforcing actions, and remaining financially viable

to ensure they can meet their full responsibilities to protect patients and

improve outcomes. Under this new process, state agency surveyors would

observe the Joint Commission or AOA surveyors to determine the

accreditors’ ability to identify problems and analyze investigation results.

HCFA officials told us that they are still working out the methodological

problems inherent in conducting simultaneous accreditation and

validation surveys. HCFA expects to implement the new hospital survey

process in fiscal year 1997.

HCFA Is

Reengineering the

PRO Program

Also as part of its Quality Improvement Program, HCFA is reengineering the

entire PRO program to incorporate continuous quality improvement

concepts. By the end of 1995, random sample case reviews—that until

1993 were the backbone of PRO review—had been completely replaced by

cooperative projects between the PROs and providers. Individual case

review will continue for seven mandatory categories38 after

implementation of the fifth round of PRO contracts beginning in

April 1996.39 However, only two of these categories appear to be primarily

aimed at identifying providers delivering poor care. These categories are

38These categories are (1) allegations of transfer of unstabilized emergency room patients to another

hospital; (2) reviews for unnecessary assistant surgeons for cataract surgery; (3) beneficiary

complaints of poor-quality care; (4) potential cases of grossly poor care or unnecessary admissions

identified during project data collection; (5) instances of hospital requests for diagnosis related group

(DRG) adjustments that would result in higher reimbursement (DRG validation only); (6) hospital- and

managed care plan-issued notices of noncoverage; and (7) all cases referred to PROs by HCFA, the

Office of Inspector General, the managed care appeals contractor, intermediaries, carriers, or clinical

data abstraction centers.

39PRO contracts are renewed in groups. The fifth contract round will be fully implemented on

October 1, 1996. PRO contracts cover 3 years.

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beneficiary complaints or possible poor care discovered in the course of

cooperative projects.

Cooperative projects are implemented by mutual agreement between the

PROs and hospitals and the PROs and HMOs with Medicare contracts.

Provider participation is voluntary. HCFA officials indicated, however, that

they believe most hospitals and HMOs will welcome the opportunity to

collaborate with the PROs on projects with the potential to improve the

quality of care. They do not believe that provider noncooperation will be a

significant problem. However, HCFA officials told us that if they have strong

indications that a hospital or HMO has significant quality of care problems

and the entity refuses to cooperate, HCFA can issue a letter terminating the

hospital’s or HMO’s Medicare participation for violating HCFA’s condition of

participation to have an effective quality assurance program.

PROs will use population, diagnosis, and procedure-specific utilization

analysis of claims and clinical data as well as current published scientific

studies to identify potential projects in areas that have clear opportunities

to improve care. Most projects are to be jointly developed by the PRO and

the provider and may involve direct data collection to supplement the use

of claims data. HCFA will direct other cooperative projects. For example,

the Cooperative Cardiovascular Project requires PROs to work with

hospitals to improve care for Medicare beneficiaries hospitalized for heart

attacks. HCFA developed a set of 11 process indicators based on an existing

clinical guideline and refined through experience in a demonstration

project involving collaboration between PROs and hospitals in four states.40

This demonstration project found that guidelines are often not followed

and that significant opportunities for improvement exist. Even among

patients who were identified as the best candidates for treatment, only

70 percent received thrombolytic drugs, 45 percent received beta blockers

at discharge, and 77 to 83 percent received aspirin. Hospitals reported that

these data were useful, and many of them committed to improving care.

The PROs in the four pilot states are now returning to the hospitals to

assess progress and promote further improvement in cardiac care for

Medicare beneficiaries. In March 1995, the Cooperative Cardiovascular

Project was extended nationwide. Data on inpatient treatment for heart

attack are being collected in the remaining 46 states, and all PROs are

expected to have collaborative projects with hospitals to improve care for

heart attack victims by mid-1996.

40The guideline used was that published by the American College of Cardiology and the American

Heart Association in 1991.

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Although PROs have the authority to review fee-for-service ambulatory

care, HCFA has been reluctant to venture into this area because reviewing

care at all U.S. private physicians’ offices would be overwhelming.

Currently, except for ambulatory surgical procedures, the only

fee-for-service ambulatory review conducted is a pilot project begun

recently in three states. In this project, PROs and 100 volunteer physicians

in each state are cooperating to improve the quality of care provided to

patients with diabetes. Concurrently, PROs in five other states are working

cooperatively with 23 HMOs on a similar project. Both the fee-for-service

and HMO initiatives are based on collecting information from medical

records about 22 specific process and outcome performance measures

such as the results of important laboratory tests.41

Data Standardization

Is a Recognized Need

As part of the new program, HCFA officials are committed to working

collaboratively with providers to enhance data requirement

standardization by making HCFA requirements consistent with other

purchasers’. As a result of these efforts, HCFA has already implemented the

minimum data set for nursing homes as previously discussed and is

developing minimum data sets for use in home health care and managed

care plans. It is now focusing efforts on standardizing data collection from

managed care plans.

HCFA officials have recognized that uniform and consistent plan data are

necessary for evaluating any managed care performance. As a result, HCFA

is working with NCQA and others to develop a new version of HEDIS that will

include information applicable to the health care needs of the Medicare

population.

HCFA Is Collaborating

With Private-Sector

Purchasers

In June 1995, HCFA announced that it was joining a group of large

corporate purchasers of health care to form a new organization called the

Foundation for Accountability. Among the many goals of this organization

is developing a new generation of quality performance measures for health

plans to provide purchasers and consumers with relevant information for

health care decisionmaking. These measures will include results of

41The diabetes indicators were developed under contract with HCFA by the Delmarva Foundation for

Medical Care and the Harvard School of Public Health with the assistance of expert panels. These

indicators include data about eye and foot examinations, blood pressure measurements, renal

function, serum cholesterol and triglyceride levels, and serum glucose levels.

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treatment both for a health system’s entire population and for sick

individuals.42

The Foundation also proposes to develop a common set of indicators to

enable consumers to compare plans and to understand a plan’s benefit

structure and modes of treatment. The Foundation will develop and use

standardized, performance-based quality and outcome measures that

emphasize patient ability to function normally in activities of daily living

and patient satisfaction with the care provided.

Because the Foundation represents approximately 80 million insured

people, HCFA and the other Foundation members believe that health plans

will adopt these measures and supply the results to them, other

purchasers, and individual consumers. According to a former HCFA

program official, joining this initiative will help to eliminate duplication of

quality assurance efforts.

Beneficiary

Satisfaction

Information

HCFA has acted to increase its knowledge about Medicare beneficiaries and

their reaction to its policies. One major initiative to obtain more

information about the demographics, health status, access to care, and

satisfaction of Medicare beneficiaries is the annual inclusion of specific

questions about these issues in the Medicare Current Beneficiary Survey.

This survey, begun in 1991, was undertaken primarily to meet the needs of

the HCFA Office of the Actuary for comprehensive information on the use

of care, costs, and insurance coverage for the Medicare population. It

entails conducting a telephone interview every 4 months with a

representative sample of 12,000 Medicare beneficiaries. Sample members

usually stay in the survey for several years.43

HCFA officials told us that they are planning a survey to collect similar data

from Medicare beneficiaries enrolled in HMOs. They said that they plan to

have an outside contractor perform annual surveys of a statistically valid

sample of Medicare enrollees in every HMO with a Medicare contract with

HCFA. The contractor will use a standard survey and provide a consistent

analysis of the information received from the beneficiaries. Data collected

42Linda Wolfe Keister, “With Health Care Costs Finally Moderating, Employers’ Focus Turns to

Quality,” Managed Care, Vol. 4, No. 10 (1995) (preprint downloaded from the Internet).

43The sample includes beneficiaries receiving care from either fee-for-service or HMO providers.

However, because beneficiaries belonging to HMOs constitute only about 10 percent of the Medicare

population, the number of such beneficiaries included in the sample is relatively small. In addition, a

HCFA official told us that only a very few of the beneficiary satisfaction questions in the survey related

to beneficiaries belonging to HMOs.

Page 30 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 3 

HCFA’s New Strategies Reflect Experts’

Views on Appropriate Quality Assurance

Approaches

in this survey will include information on member satisfaction, quality of

care, and access to services. HCFA has not yet begun the contracting

process, however.

HCFA officials told us that they intend to use the results of this survey to

monitor contracting HMOs as well as to translate the resulting data into

information that will be meaningful to beneficiaries and others for making

informed health care decisions. HCFA also intends to release the results of

the surveys to the plans for use in the plans’ continuous quality

improvement activities.

Beneficiary Education

Focuses on Personal

Health, Not Provider

or Plan Information

HCFA is conducting promotional campaigns intended to increase Medicare

beneficiaries’ use of influenza immunizations and screening

mammographies. Educational information about additional topics, such as

post-acute care alternatives and end-stage renal disease are being

developed.

HCFA officials eventually plan to provide Medicare beneficiaries with

information that will help them choose providers. Within a few years, they

expect to be able to report the characteristics and results of key

performance indicator data for nursing homes to facilitate consumer

comparison of facilities. Producing these reports is difficult, however,

because it requires adjusting nursing home comparisons for resident

populations with differing care needs. Presenting the results of such a

comparison in a clear enough way to be useful to consumers will also be a

complex task. At best, it may be several years before this initiative shows

concrete results.

HCFA officials also reported that they are planning to produce a “Plan

Comparability Chart,” another initiative designed to provide beneficiaries

with information to compare Medicare HMOs and HMOs versus

fee-for-service arrangements. However, this project appears to be in its

early stages. In a recent report, we found that, although HCFA does collect

information that could be useful to beneficiaries in discriminating among

HMOs, it does not routinely make such information available.44 HCFA

regularly reviews plan performance and routinely collects and analyzes

data on Medicare HMO enrollment and disenrollment rates, Medicare

appeals, beneficiary complaints, plan financial condition, availability and

access to services, and marketing strategies. However, HCFA does not make

this information routinely available to beneficiaries, nor does it plan to do

44Health Care (GAO/HEHS-95-201, Sept. 29, 1995).

Page 31 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 3 

HCFA’s New Strategies Reflect Experts’

Views on Appropriate Quality Assurance

Approaches

so. In another recent report, we recommended that HCFA be directed to

routinely publish comparative data it collects on Medicare HMOs and the

results of its investigations and any findings of noncompliance by HMOs.45

45Medicare (GAO/HEHS-95-155, Aug. 3, 1995).

Page 32 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 4 

Conclusions and Agency Comments

HCFA’s proposed changes to enhance its quality assurance programs are

generally consistent with the strategies expressed by the experts we

interviewed and the literature we reviewed on assessing quality in the

Medicare program. These changes appear to be steps in the right direction.

We have concerns, however, about HCFA’s implementation of its new

quality assurance strategy and its plans and timetable for providing

information to beneficiaries.

Our analysis of HCFA’s previous quality assurance implementation efforts

raises concerns about whether HCFA will implement its new

comprehensive program to deal effectively with poorly performing health

care providers as well as improve all providers’ performance. As the

majority of experts we interviewed recommended, HCFA’s Health Care

Quality Improvement Program is based on continuous quality

improvement. HCFA plans, however—through its targeted medical record

review—to continue its efforts to identify providers who do not meet

accepted standards of practice. But the number of targeted reviews

planned could be minimal. The ability of HCFA’s proposed program to focus

on dealing effectively with poorly performing providers is unclear, and this

is an area where HCFA has not performed well in the past.

HCFA’s plans and timetable for implementing patient satisfaction surveys

and distributing comparative performance measurement information lag

behind those of some private-sector employers and state agencies because

HCFA does not believe it has useful information to give beneficiaries. We

agree that HCFA should proceed with due care before implementing

programs that might mislead beneficiaries about the quality of care they

would receive in different health care systems. However, other responsible

purchasers have already proceeded with surveying their constituents to

determine their feelings about their health care and have published

satisfaction data and other performance information to help individuals

make purchasing decisions. Those who received the information say they

found it useful and requested more data.

HCFA Comments and

Our Evaluation

The Administrator of the Health Care Financing Administration disagrees

with our concerns over how well HCFA will be able to implement its new

quality assurance initiative and its plans for providing information to

beneficiaries. The Administrator also notes that we do not mention HCFA’s

Long Term Care Enforcement Regulation and provides detailed technical

comments on our report (see app. I).

Page 33 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 4 

Conclusions and Agency Comments

GAO Work on HCFA’s

Quality Assurance

Activities

The Administrator said that our report inaccurately and unfairly concludes

that HCFA cannot implement comprehensive programs and deal effectively

with poorly performing health care providers. He states that our reports

have presented an unbalanced view of HCFA’s quality assurance initiatives

over the years, choosing to focus on negative events in the past rather than

HCFA’s continuous improvements to its quality monitoring. For example,

we have criticized HCFA in the past for failing to enforce HMO quality

assurance standards, citing the example of a Florida HMO. The

Administrator notes that we do not mention a HCFA investigation of this

HMO in 1994 and 1995, the deficiencies HCFA identified, and the corrective

actions the plan agreed to implement. In addition, the Administrator

disagrees with our conclusion that HCFA should not rely totally on a

continuous quality improvement strategy since this could result in

deemphasizing the identification and correction of substandard providers.

He argues that our report suggests that HCFA’s resources should be devoted

to identifying substandard providers. Furthermore, the Administrator

states that we cite but a few poor performers and indicates that the only

way to improve care for Medicare beneficiaries is to terminate

participation by these facilities.

Our reports, as noted by the Administrator, have consistently documented

HCFA’s failure to aggressively enforce HMO-related quality assurance

requirements. We believe that the history of our work raises reasonable

concerns about how well HCFA will implement its current quality assurance

initiative and take action if providers are not adequately improving their

performance. In several reports prepared in the past decade covering both

the provider certification and HMO qualification programs, we have found

that HCFA has often failed to act firmly even when the provider is not

making good faith efforts or acceptable progress. In our opinion, the

events leading up to and surrounding the 1994 investigation of the HMO

mentioned by the Administrator are an excellent example of HCFA’s

difficulties in enforcing Medicare requirements for HMOs. In January 1993,

HCFA was aware of findings from a 1992 special study performed by the

Florida PRO that showed serious quality problems at this HMO. Despite this

awareness, HCFA did not begin to investigate the HMO’s quality assurance

and utilization management practices until June 1994. HCFA approved a

corrective action plan for this HMO in January 1995 and found it in

compliance in July 1995—more than 2-1/2 years after the problem first

surfaced.

Despite the Administrator’s statement, our report does not propose

devoting all of the program’s resources to identifying substandard

Page 34 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 4 

Conclusions and Agency Comments

providers. Rather, we are concerned about how HCFA will balance its use

of continuous quality improvement with ways to deal effectively with

poorly performing providers. Additionally, we do not believe, as HCFA

indicates, that the only way to improve care for Medicare beneficiaries is

to terminate providers from the program. In some instances, however, this

may be HCFA’s only recourse if the provider repeatedly fails to take

corrective action. We have modified our language in the report to clarify

our position on this matter.

HCFA’s Consumer

Education Effort

The Administrator also disagrees with what he characterizes as our

conclusion that HCFA has no immediate plans to provide beneficiaries with

health plan-specific information to help them in making health care

purchasing decisions. Instead, he notes that HCFA recognizes the need to

provide information that is truly usable and informative. The

Administrator adds that GAO does not go into any detail on the usefulness

of information issued by the private sector. He argues that at best such

information is very sketchy and cannot be used to make a managed care

plan choice. First, we agree that HCFA should publish only useful

information; however, we believe that some of the information now being

collected by HCFA qualifies as useful and could be published and

disseminated to Medicare beneficiaries. This includes information on HMO

disenrollment rates and beneficiary complaints. In addition, HCFA could

routinely release its HMO site visit reports. These reports contain

information that might be useful to beneficiaries, for example, how well

the HMO is meeting Medicare requirements such as maintaining an effective

quality assurance program and a Medicare appeals system. The reports do

not normally contain provider-specific information that HCFA indicates

regulations prohibit it from releasing and are currently available to the

public only under Freedom of Information Act procedures. We also are

convinced that HCFA beneficiaries could benefit from private-sector

strategies for collecting and disseminating information about quality and

value and have provided an additional reference to support our belief that

consumers would use this information.

Long Term Care

Enforcement Regulation

The Administrator also notes that our report does not mention the Long

Term Care Enforcement Regulation and the training efforts that have

occurred to enhance the effectiveness of both the enforcement regulation

and the long-term care survey process. We have added a description of

HCFA’s Long Term Care Enforcement Regulation to our report.

Page 35 GAO/HEHS-96-20 Medicare Quality Assurance
Chapter 4 

Conclusions and Agency Comments

HCFA also made other detailed comments on specific portions of our draft

report. We have considered these and modified our report where

appropriate.

Page 36 GAO/HEHS-96-20 Medicare Quality Assurance
Page 37 GAO/HEHS-96-20 Medicare Quality Assurance
Appendix I 

Comments From the Department of Health

and Human Services

Page 38 GAO/HEHS-96-20 Medicare Quality Assurance
Appendix I 

Comments From the Department of Health

and Human Services

Page 39 GAO/HEHS-96-20 Medicare Quality Assurance
Appendix I 

Comments From the Department of Health

and Human Services

Page 40 GAO/HEHS-96-20 Medicare Quality Assurance
Appendix II 

Experts Interviewed

The names and positions of the following experts as well as of the

organizations are as of May 1995, when we conducted these interviews.

American Association of

Preferred Provider

Organizations

Lisa Sprague, Director of Legislative Affairs

Gordon B. Wheeler, President and Chief Operating Officer

American Association of

Retired Persons

Mary Ellen Bliss, Regulatory Associate, Federal Affairs Department

Joyce Dubow, Senior Analyst, Public Policy Institute

Mary Jo Gibson, Senior Analyst, Public Policy Institute

Alan K. Kaplan, Consultant to American Association of Retired Persons

American Group Practice

Association

Julie A. Sanderson-Austin, Director, Quality Management and Research

American Hospital Association Karen A. Milgate, Associate Director, Policy Development

Ellen A. Pryga, Director, Health Policy

Southern California Edison Pamela A. Kroll, Health Plans Manager

Suzanne C. Mercure, Manager of Benefits Administration

Colorado Hospital Association Larry H. Wall, President

ConsumerFirst Clark E. Kerr, President

Department of Veterans Affairs Dr. Galen L. Barbour, Associate Chief Medical Director for Quality

Management, Office of Quality Management

M. Scott Beck, Director, Office of Planning and Evaluation, Office of

Quality Management

Debby Walder, Director, Office of Risk Management, Office of Quality

Management

Federation of American Health

Care Systems

Thomas A. Scully, President and Chief Executive Officer

Good Samaritan Health System Dr. Molly J. Coye, Senior Vice President, Clinical Operations

Group Health Association of

America

Kelli Back, Senior Policy Associate, Government Affairs

Carmella Bocchino, Director of Medical Affairs

Julie Goon, Director of Legislative Affairs

Candace Schaller, Director of Policy, Government Affairs

Page 41 GAO/HEHS-96-20 Medicare Quality Assurance
Appendix II 

Experts Interviewed

Group Health Cooperative of

Puget Sound

Kathleen Cromp, Director of Quality of Care Assessment

Harvard School of Public

Health

Dr. R. Heather Palmer, Director, Center for Quality of Care Research and

Education

Health Care Financing

Administration

Gary Bailey, Team Leader, Beneficiary Access and Education Team, Office

of Managed Care

Paul D. Elstein, Team Member, Quality and Performance Standards Team,

Office of Managed Care

Dr. Stephen Jencks, Senior Clinical Advisor, Health Standards and Quality

Bureau

Tracy L. Jensen, Legislative Liaison, Office of Managed Care

Jean D. LeMasurier, Team Leader, Program, Policy and Improvement

Team, Office of Managed Care

Health Pages Magazine Carol Cronin, Senior Vice President

Henry Ford Health System Dr. David R. Nerenz, Director for Center of Health System Studies

Jackson Hole Group Dr. Sarah Purdy, Health Policy Analyst

John Deere Health Care, Inc. Dick Van Bell, President

Geri Zimmerman, Director of Quality Management Programs

Joint Commission on

Accreditation of Healthcare

Organizations

Dr. Paul M. Schyve, Senior Vice President

Margaret VanAmringe, Associate Director, Government Relations

Midwest Business Group on

Health

James D. Mortimer, President

National Capitol Preferred

Provider Organization

Dr. Robert Berenson, Medical Advisor

National Committee for Quality

Assurance

Steven Lamb, Director of Government Relations

Margaret E. O’Kane, President

Park Nicollet Medical

Foundation

Dr. Jinnet Fowles, Vice President, Research and Development

Page 42 GAO/HEHS-96-20 Medicare Quality Assurance
Appendix II 

Experts Interviewed

Physician Payment Review

Commission

David C. Colby, Principal Policy Analyst

Prudential Center for Health

Care Research

Dr. William L. Roper, President

The RAND Corporation Dr. Elizabeth A. McGlynn, Health Policy Analyst, Health Sciences Program

State of Florida Randy Mutter, Administrator, Research and Analysis Section, Agency for

Health Care Administration

State of Michigan Janet Olszewski, Chief, Division of Managed Care, Michigan Department of

Public Health

Thomas Jefferson University

Hospital

Dr. Leona E. Markson, Associate Director, Clinical Outcomes Research

Dr. David B. Nash, Director, Office of Health Policy and Clinical Outcomes

UNIVA Health Network Dr. William Jesse, President and Chief Executive Officer

Utilization Review and

Accreditation Commission

Randall H. H. Madry, Executive Director

Washington Business Group on

Health

Sally Coberly, Director

Wisconsin Peer Review

Organization

Dr. Jay A. Gold, Principal Clinical Coordinator

Page 43 GAO/HEHS-96-20 Medicare Quality Assurance
Appendix III 

Accrediting Organizations

Table III.1: Organizations Whose

Accreditation HCFA Deems to Be

Adequate Assurance That Providers

Meet HCFA Conditions of Participation

Type of provider Accrediting organization

Hospitals Joint Commission on Accreditation of

Healthcare Organizations

American Osteopathic Association

Home health agencies Joint Commission on Accreditation of

Healthcare Organizations

Community Health Accreditation Program

Laboratories under the Clinical Laboratories

Improvement Act

Joint Commission on Accreditation of

Healthcare Organizations

College of American Pathologists

American Society for Histocompatability

and Immunogenetics

American Association of Blood Banks

American Osteopathic Association

Page 44 GAO/HEHS-96-20 Medicare Quality Assurance
Appendix III 

Accrediting Organizations

Table III.2: Organizations That Accredit

Institutional Health Care Providers or

Units Within Providers

Accrediting organization Type of provider accredited

Joint Commission on Accreditation of

Healthcare Organizations

Hospitals, skilled nursing facilities, home

health agencies, health networks, and

others

American Osteopathic Association Hospitals and laboratories

National Committee on Quality Assurance Managed care plans

Commission on Accreditation of

Rehabilitation Facilities

Rehabilitation facilities

Commission on Office Laboratory

Accreditation

Physician office laboratories

College of American Pathologists Laboratories

American Association of Ambulatory Health

Care

Ambulatory health centers and ambulatory

surgical centers

American Society of Histocompatibility and

Immunology

Laboratories performing tissue-typing and

related tests

American College of Surgeons Trauma systems

American Speech and Hearing Association Speech and hearing programs

Commission on Accreditation of Free

Standing Birthing Centers

Freestanding birthing centers

National Commission on Correctional Health

Care

Health units in correctional facilities

American Association of Blood Banks Laboratories

Utilization Review Accreditation Commission Freestanding utilization review programs

and utilization review programs in HMOs

and preferred provider organizations (PPO)

American College of Radiology Diagnostic and therapeutic radiology units

in all settings

Community Health Accreditation Program Home health agencies

American Accreditation Program, Inc. PPOs

Page 45 GAO/HEHS-96-20 Medicare Quality Assurance
Appendix III 

Accrediting Organizations

Page 46 GAO/HEHS-96-20 Medicare Quality Assurance
Appendix III 

Accrediting Organizations

Page 47 GAO/HEHS-96-20 Medicare Quality Assurance
Related GAO Products

Health Care: Employers and Individual Consumers Want Additional

Information on Quality (GAO/HEHS-95-201, Sept. 29, 1995).

Medicare: Increased HMO Oversight Could Improve Quality and Access to

Care (GAO/HEHS-95-155, Aug. 3, 1995).

Medicare: Enhancing Health Care Quality Assurance (GAO/T-HEHS-95-224,

July 27, 1995).

Community Health Centers: Challenges in Transitioning to Prepaid

Managed Care (GAO/HEHS-95-138, May 4, 1995); testimony on the same topic

(GAO/T-HEHS-95-143, May 4, 1995).

Medicare: Opportunities Are Available to Apply Managed Care Strategies

(GAO/T-HEHS-95-81, Feb. 10, 1995).

Health Care Reform: “Report Cards” Are Useful but Significant Issues

Need to Be Addressed (GAO/HEHS-94-219, Sept. 29, 1994).

Home Health Care: HCFA Properly Evaluated JCAHO’s Ability to Survey

Home Health Agencies (GAO/HRD-93-33, Oct. 26, 1992).

Home Health Care: HCFA Evaluation of Community Health Accreditation

Program Inadequate (GAO/HRD-92-93, Apr. 20, 1992).

Medicare: HCFA Needs to Take Stronger Actions Against HMOs Violating

Federal Standards (GAO/HRD-92-11, Nov. 12, 1991).

Health Care: Actions to Terminate Problem Hospitals From Medicare Are

Inadequate (GAO/HRD-91-54, Sept. 5, 1991).

Medicare: PRO Review Does Not Ensure Quality of Care Provided by Risk

HMOs (GAO/HRD-91-48, Mar. 13, 1991).

Medicare: Physician Incentive Payments by Prepaid Health Plans Could

Lower Quality of Care (GAO/HRD-89-29, Dec. 12, 1988).

Medicare: Experience Shows Ways to Improve Oversight of Health

Maintenance Organizations (GAO/HRD-88-73, Aug. 17, 1988).

Medicare: Issues Raised by Florida Health Maintenance Organization

Demonstrations (GAO/HRD-86-97, July 16, 1986).

(101468) Page 48 GAO/HEHS-96-20 Medicare Quality Assurance
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