Envision an old Western movie where the local law-and-order sheriff deputizes a band of citizens to hunt down a desperado. Later, this newly empowered gang of vigilantes captures the bad guy and beats him bloody before hauling him back to the sheriff. An idea that started with good intentions ends in shambles.
Although not as dramatic as a cowboy movie, that same kind of scenario might unfold if the federal government follows through with a proposal to force Medicare peer review organizations to search for hospital fraud and payment errors.
The 37 designated PROs are charged with identifying and correcting deficiencies in the quality of care provided to Medicare enrollees. For example, the PRO movement has publicized the medical benefit of administering aspirin to heart attack patients in the emergency room. The PROs are being paid a total of $520 million during a three-year cycle that ends next Sept. 30.
In the following three-year cycle, HCFA wants the PROs to sniff out crooked healthcare providers by analyzing hospital data and reviewing individual patient records. This, HCFA believes, will allow the PROs to identify patterns of improper billing, DRG upcoding and inappropriate patient transfers. The reports would then be turned over to HHS' inspector general's office or the U.S. Department of Justice.
Oversight and whistleblowing might be effective deterrents, but turning PROs into detectives will divert them from their primary focus of analyzing patterns of care to improve quality. Moreover, the relationship between providers and their PROs will surely deteriorate once the sleuthing begins.
Surely, the federal government has enough agents searching for hospital fiscal deception. Even though the Clinton administration has sounded a moralistic crusade against healthcare cheats, Medicare patients are better served if the PROs stick to improving quality.