Arguing that it would hinder government efforts to improve patient care, the American Hospital Association has come out against turning over the investigative records of Medicare peer review organizations to beneficiaries.
In doing so, the AHA has sided with the Centers for Medicare and Medicaid Services, which is considering an appeal of a recent federal court decision ordering the agency to open up PRO findings involving beneficiary complaints.
Meanwhile, HHS' inspector general's office released a report last week that said Medicare falls short when it comes to investigating complaints, reporting back to beneficiaries and disciplining providers.
The new criticism of the Medicare complaint process comes as the CMS seeks to extend a stay from an order by the U.S. District Court in Washington to direct PROs to disclose complaint investigations to beneficiaries. In July, the court ruled as illegal Medicare's policy of having PROs turn over its findings about a physician only with that physician's approval (July 23, p. 4).
Judge Ellen Huvelle's ruling called for the CMS to notify PROs by July 31 that they are required to disclose the results of their investigations into beneficiary complaints. But Huvelle stayed the order while the CMS determines whether it will appeal. At deadline, Huvelle was expected to rule on the CMS' motion to continue the stay. The agency has until Sept. 12 to file for an appeal.
In a 53-page report released last week, HHS' inspector general's office found that PROs aren't accessible to beneficiaries, rarely respond to complaints with more than an educational form letter to providers, and don't make their findings from investigations available to complainants (See chart).
"Beneficiaries looking for an easy-to-use complaint system that will hold physicians and facilities accountable for quality-of-care problems and respond to beneficiaries in a meaningful way will be left frustrated and disappointed" by the PROs' process, according to the report.
In response, PRO officials said that to handle complaints adequately they need four to eight times more money than they now receive for the task under their contracts with the CMS.
"Something has got to give; either the work has to be redefined or the funding has to be increased," said David Schulke, executive vice president of the American Health Quality Association, a professional association representing PROs. Medicare contracts with 37 PROs to serve every state and territory in the U.S. at an annual cost of about $246 million.
A CMS spokesman said the agency believes that this level of funding is adequate for the PROs to do their core work, including handling beneficiary complaints.
In addition, the inspector general's report said PROs, which cite clinical quality improvement as their highest priority, are reluctant to risk damaging their working relationships with the medical community by aggressively investigating complaints. PROs have referred just six providers for sanctions in the past five years and none in the past two years.
The AHA believes the quality-improvement model the PROs use to address beneficiary complaints "works very well," said Anne Berdahl, the association's senior associate director of health policy development.
Last week, the AHA sent a letter to HHS supporting the government's request for a stay of the court's order to share findings of complaints. The AHA said the court's order "would not be in the best interests of the public in the delivery of safe, quality healthcare." The letter also states that without legal protection, physicians will be unlikely to participate in meaningful peer review.
Officials of the American Medical Association declined to be interviewed for this article.
The AHA says other authorities, such as state licensing boards, state health departments and accrediting bodies can be used to provide the public with greater accessibility and feedback for complaints concerning Medicare providers and should have an expanded role in the process.
"Beneficiaries should be aware there are other regulatory processes that may serve their needs in that capacity better," Berdahl said.
The AHA has opposed the use of federally collected data on medical errors by the Joint Commission on Accreditation of Healthcare Organizations in making its hospital accreditation decisions (Aug. 13, p. 4).
The inspector general's report points out shortcomings with relying on these processes for complaint handling. Professional licensing boards have "struggled" with quality-of-care complaints, and the JCAHO gives patients' complaints limited attention, according to the report.
The JCAHO takes exception to this assessment, which the inspector general's office first raised in a 1999 report.
"We think we have an extremely effective complaint process," said Margaret VanAmringe, the JCAHO's vice president for external relations. She said the Joint Commission would like to access PROs' complaint data. "PROs in general have not coordinated as well as they should have with accreditors," VanAmringe said.
Criticisms of the Medicare complaint process aren't new. A 1995 report by the inspector general's office said PROs were slow to respond to complaints and that federal confidentiality laws limited how forthcoming the organizations could be.