Peer review is down but not out in the private Medicare plans being considered by congressional leaders.
Medicare-reform legislation passed earlier this month by the House Ways and Means Committee and House Commerce Committee would allow Medicare health plans to bypass external quality review if a private-sector accreditation organization certifies that the plans meet the quality standards outlined in the legislation.
The measure aims to give beneficiaries options beyond traditional Medicare fee-for-service.
The Senate Finance Committee last week was preparing to consider an amendment to its version of Medicare reform legislation to maintain external review of the quality of care delivered through private-sector Medicare health plans.
Such a provision probably would still mean a reduced role in the private-sector health plan market for the 39 Medicare peer-review organizations, which analyze providers' utilization and quality and identify opportunities for improvements.
House Republicans have argued in favor of "deeming" health plans as meeting quality standards through such private accreditation bodies as the National Committee for Quality Assurance, rather than continuing the quasi-public role of the peer-review organizations.
"The members felt the private sector was a better way to go," said a Ways and Means Committee staffer.
The Congressional Budget Office estimates the proposal would save $100 million between 1998 and 2002, the year Congress wants to balance the budget. HCFA estimates it will pay $270 million in federal fiscal 1997 to the PROs, which now prefer to be called quality improvement organizations.
But consumer advocates oppose the House proposal. A letter to congressional leaders from 35 organizations highlighted the elimination of quality review as one of eight issues they say will weaken beneficiary protections.
"Private accreditation is not enough," said Cheryl Matheis, a legislative representative for the American Association of Retired Persons, which signed the letter. "Just because a plan has the capacity to deliver quality care does not mean that it is delivering quality care."
The amendment proposed to the Senate Finance Committee by the American Health Quality Association, the NCQA and other organizations stipulates that each Medicare private health plan contract with an independent quality improvement and review organization in addition to requiring accreditation by independent organizations.
"It's distinctly different work," said Lisa Weiss, associate executive vice president of the AHQA, which represents the quality improvement groups. "We think there needs to be two lines of business."