The head of a peer review organization trade group says a recent government decision demonstrates that PROs can be a lot more than just Medicare cops.
Josef Reum, executive vice president of the American Health Quality Association, was referring to HCFA's selection of a Medicare PRO-Island Peer Review Organization of Lake Success, N.Y.-to audit quality data submitted by Medicare HMOs.
Reum said the decision bolsters his contention that PROs can evolve into a powerful force for the improvement of healthcare quality in changing times.
"Our largest customer, HCFA, recognizes that more than half of our members have been doing work in managed care," Reum said. "This moves us into a new relationship with our largest customer."
The selection is in keeping with a continuing effort on the part of the PROs-or, as they prefer to be called now, "quality improvement organizations," or QIOs-to diversify their businesses.
Instead of focusing on punitive, retrospective reviews of providers' performance on specific Medicare cases, the QIOs say they now are trying to focus more on how to improve providers' performance in treating patients covered by both private and public-sector payers.
Medicare PROs were created under a 1982 law, when nearly all Medicare services were provided on a fee-for-service basis. But the growth of managed care has forced providers and the organizations that monitor them to evolve.
HCFA projects it will pay the nation's 38 PROs $270 million in fiscal 1997, which ends Sept. 30, to conduct their normal reviews of Medicare health quality.
HCFA last month selected IPRO to audit the accuracy and validity of Health Plan Employer Data and Information Set figures being submitted to HCFA by about 250 Medicare managed-care plans. Those data are to be submitted by the end of June. IPRO is getting an extra $500,000 to perform the new quality audit.
IPRO already has audited quality data submitted by managed-care plans to New York, some of which are HEDIS measures and some of which are Medicaid-related indicators, said Herman Jenich, IPRO's senior director of managed-care evaluation.
The audit will be in two parts. The first part will be a "desk audit," examining the data submitted by health plans on four Medicare-related performance measures.
The second part will be on-site audits of 60 plans, half of which will be chosen at random and half of which will be chosen because their data had discrepancies or their performance seemed unusually good or bad.