The Medicare peer review community, which once spent its time auditing patient records, now focuses on analyzing patterns of care and identifying where providers can improve.
The Medicare quality-improvement organizations-the generic name now used by the peer review organizations, or PROs-are completing their first HCFA contracts under a program in which they seek to be a partner in improving the care delivered by hospitals and other providers.
The effort is expected to yield greater quality payoffs in the coming year.
Instead of punitive, retrospective reviews of a sample of specific cases, the former PROs are using patient data to identify places where providers can deliver better care, as well as giving them the tools to make improvements and monitor progress.
For example, one project found that despite research showing that giving heart attack victims aspirin within one hour of the attack reduces the chance of subsequent attacks, only four in 10 Medicare patients admitted to hospitals because of heart attacks were given aspirin.
Such findings show hospitals and other providers where they may be able to change their practices and make sure practitioners adopt those changes so patients don't require future hospitalization or risk death.
"Standard practice is something that changes slowly," said Regine Buchanan, quality management director for the American Medical Peer Review Association, or AMPRA, which represents the quality-improvement organizations. "Hospitals are very enthusiastic about working on something that's relatively simple to do."
Advocates of the new quality-improvement process believe that if providers are given the right information and the procedures to improve care, quality-improvement groups will have less need in the future to review patient records with an eye toward punishing providers who gave inappropriate care.
"We're not in the peer review business anymore," said Lisa Weiss, interim executive vice president of AMPRA. "It really doesn't represent what we do anymore."
The peer review community's shift has even earned praise from such onetime adversaries of the system as the American Medical Association.
"(Doctors) don't feel that the PRO is a policeman," said Mark Segal, director of medical practice financing and systems at the AMA. "They feel that the PROs can really work as a partner."
"I think what we're seeing is a transformation (of Medicare peer review) in part because of the transformation of the healthcare system, but also in part because there was only limited value in case-by-case review," said Jack Lord, M.D., the American Hospital Association's senior adviser for clinical affairs.
The contract, sometimes called a "scope of work," that the quality-improvement groups now are completing served as a transition from the retrospective review format. All the quality-improvement groups will be operating under the new contract by the end of the year. Although no specific target areas are spelled out, HCFA has high expectations for PROs identifying deficiencies as a way to seek quality-improvement opportunities.
"Now we anticipate and are beginning to see a steady flow of documented opportunities for improvement and action strategies that are being applied," said Steven Helgerson, M.D., deputy director of the quality-improvement program in HCFA's health standards and quality bureau. "We would like to see improvement documented for a large proportion of Medicare beneficiaries."
However, the change in the peer review community's mode of operations is not without its critics.
For instance, Donald Young, M.D., executive director of the Prospective Payment Assessment Commission, attributed increases in Medicare inpatient hospital spending-and the deteriorating condition of the Medicare Hospital Insurance Trust Fund-partly to the quality-improvement focus.
"Now that they're moving to the quality side rather than the policing side, it's taking some of the pressure off," Young said.
Helgerson responds, however, that not all the data indicate Medicare hospital admissions and spending have increased more than expected. Although AHA data indicate Medicare admissions have been greater than projected, HCFA data show the admissions have been closer to projections.
Furthermore, contends ProPAC commissioner Roxane Spitzer, as Medicare beneficiaries increasingly enroll in managed-care plans, a HCFA-directed quality-improvement program may be duplicative because health plans have their own internal quality activities.
"I'm not sure, as we evolve toward managed care, that they're the right body," said Spitzer, associate dean for practice management at Vanderbilt University and executive director of Vanderbilt University Community Health System. "I think it's duplicative of a mechanism that's not in place but moving very rapidly toward being in place."
But Helgerson said the quality-improvement efforts still have a place because most Medicare beneficiaries still receive care on a fee-for-service basis.
Officials from the Arizona Health Services Advisory Group contend the independent assessment still is necessary even if HMOs have their own quality-improvement structures. The group in 1994 pioneered a cooperative quality-improvement collaboration with the state's six Medicare managed-care plans that has become a model for other states.
"We do, in a sense, have an arm's-length relationship with managed-care organizations. They don't pay us," said Lawrence Shapiro, M.D., president of the Arizona group.
Furthermore, adds Herb Rigberg, M.D., the group's medical director, HMOs that rely only on internal quality measures won't know how they compare with their competitors.
"That doesn't come out if you're looking at your own data," Rigberg said.