The trade group representing Medicare's quality peer-review organizations last week plunged into the managed-care regulation debate, saying reform would extend existing protections for Medicare beneficiaries to all insured patients.
The American Health Quality Association said private-sector health plans should be subject to the same requirements for accreditation, external quality review and third-party grievance appeals that Medicare plans face. Those requirements were imposed as part of last year's balanced-budget legislation.
The PROs serve as Medicare contractors in reviewing utilization and quality. In their current contracts, the 53 PROs have been focusing on patterns of care to detect where quality can be improved, rather than on punitive, retrospective case review.
As organizations already performing external quality review of Medicare plans and providers, the PROs would be well-positioned to also serve as the quality monitors of private-sector health plans.
"Clearly, it's a business opportunity, but in terms of the public policy of improving health status, it's the right thing to do," said Lisa Weiss, associate executive vice president of the Washington-based AHQA.