HCFA's administrator said last week that a six-year pattern of hospital noncompliance with Medicare quality norms is evidence that standards are high and inspectors are vigilant, not that substandard hospitals are getting a clean bill of health.
Bruce Vladeck, Medicare's top official, responded to disclosures by Public Citizen's Health Research Group that at least one in five hospitals is being accredited by the Joint Commission on Accreditation of Healthcare Organizations despite failure to meet one or more "conditions of participation" in the Medicare/Medicaid program.
The conditions set by HCFA cover 20 broad areas, such as quality assurance, infection control, hospital conditions and clinical services.
Citing HCFA's follow-up inspections to validate JCAHO surveys in 1987 through 1992, Public Citizen charged in a letter to Mr. Vladeck that HCFA should reconsider relying on JCAHO accreditation, which automatically doubles as Medicare qualification.
Validation surveys showed 34% of sampled hospitals didn't meet all Medicare conditions in 1992, and the percentage stood at 20% or more for all years studied (June 27, p. 8).
"Assuming that everything is OK because of accreditation is not something (HCFA) should be doing," said Joan Stieber, staff attorney for the Health Research Group. The authority to deem hospitals eligible for Medicare "means that if a hospital is accredited by the JCAHO, it is presumed to meet these conditions of participation."
But Mr. Vladeck disagreed with that presumption, saying it's tantamount to requiring a perfect score from hospitals rather than a comfortably passing grade.
"I don't think it's reasonable to expect every institution to be in compliance every day with the complete standards of accreditation," he said.
The benefit of testing hospital compliance with standards, he said, is in identifying problems and establishing a plan of correction, which is an emphasis of the accreditation process and the HCFA inspection. And he said the rate of noncompliance with Medicare standards shows that the program works: "If it were lower, either standards were too low or inspectors aren't doing their jobs."
But giving hospitals leeway instead of treating Medicare conditions as minimums is confusing to consumers trying to determine whether hospitals are fit or not, said Ms. Stieber. "You need to establish a threshold for accountability," she said. "How much noncompliance is too much noncompliance?"
Public Citizen contends that HCFA-conducted surveys are more public and accountable because they're done by a unit of government instead of a private organization and because they impose "a tight schedule for ensuring that corrections are made," Ms. Stieber said.
The JCAHO's process frequently includes a correction plan, but hospitals are allowed to correct problems under a status called "accredited with Type I recommendations." That masks problems while according accreditation for public consumption, she said.