In their quest to move from case-by-case reviews to monitoring patterns of care, Medicare peer review organizations have all but stopped identifying poor-performing hospitals and physicians, a government audit shows.
In addition, they rarely follow up on those cases they do detect.
The HHS' inspector general's office report found that as recently as 1987, PROs referred more than 70 cases per year to the inspector general for sanctions. Since then the average has been only 13 a year.
Much of the decrease can be attributed to a new direction undertaken by PROs. Beginning in 1993, PROs moved away from case-by-case reviews to what is called the Health Care Quality Improvement Programs. Under the new system, PROs review practice patterns searching for cases that fall outside the norm in terms of both quantity and quality.
The shift was implemented largely due to complaints from providers that felt the system had become too punitive and too costly, according to Andrew Webber, executive vice president of the American Medical Peer Review Association.
The inspector general's report recommended that HCFA either relieve the PROs of responsibility for detecting poor-performing doctors and hospitals and give it to another body, such as state medical boards, or find a way to make it easier for PROs to monitor systems of care and detect poor performance at the same time.
According to Webber, the new PRO charter "shows promise for evaluating the full range of practice performance including those providers on the tail end of the performance distribution."
"AMPRA contends that...the more scientific and systems-oriented approach to identifying and responding to poor performers might prove to be a more effective strategy than the subjective and highly litigious system of individual case review," Webber added.
The American Medical Association, which was sharply critical of the old case-by-case approach, said it supported the new Health Care Quality Improvement Programs and believed the system was sufficient to detect cases of poor quality.