Medicare's peer review community is trying to expand its domain by selling its quality improvement services to private-sector providers.
A growing share of the work of the nation's 38 statewide or multistate peer review organizations involves such private-sector ventures as reviewing workers' compensation data, hearing consumer appeals when health plans deny care and investigating healthcare fraud, said Josef Reum, executive vice president of the American Health Quality Association, which represents PROs.
To draw more of such business, PROs-which now prefer to be called quality improvement organizations, or QIOs-are trying to position themselves as the only nationwide network of locally based, locally managed quality improvement groups. They hope to sell their services to the other big players in the healthcare quality game-namely the National Committee for Quality Assurance and the Joint Commission on Accreditation of Healthcare Organizations.
QIO leaders hope the growing nonfederal activities of the organizations will show that Medicare no longer is their exclusive focus.
"It can't be," Reum said. "Medicare alone is not what the healthcare world is all about right now." Reum came on board with the AHQA in September, just before it changed its name from the American Medical Peer Review Association.
Although cautioning that HCFA and QIOs need to safeguard against conflicts of interest, HCFA officials said they support increased private-sector work by the quality groups.
"It reduces the amount of overhead charged solely to the Medicare program," said Mary Laureno, co-director of the center for clinical measurement and improvement in HCFA's health standards and quality bureau.
HCFA expects the Medicare program to pay $270 million to QIOs in fiscal 1997.
Laureno added that analyzing providers' care of nonelderly people allows QIOs to "learn things from the private sector" that they can apply to quality improvement for Medicare beneficiaries.
Because it has changed its strategic direction from punitive, retrospective record review to prospective quality improvement projects, the AHQA is now receiving praise from onetime adversaries such as the American Medical Association.
The QIOs' new focus on collaboration and increased nonfederal and private-sector work also is getting praise from some of the other quality assessment organizations.
JCAHO President Dennis O'Leary, M.D., said his organization, which accredits providers as meeting quality standards, and the QIOs "come at quality improvement from different directions," which can allow the two groups to work together in complementary roles. The JCAHO has teamed up with QIOs in bids for Medicaid quality review contracts in California and New York, O'Leary said.