MEDICARE -- Copyright -- Contents -- Preface -- Introduction to the Study and This Report -- CONGRESSIONAL CHARGE -- STUDY METHODS -- ORGANIZATION OF THIS REPORT -- Summary -- FINDINGS AND CONCLUSIONS -- A MODEL OF QUALITY ASSURANCE FOR MEDICARE -- DEFINING QUALITY OF CARE -- RECOMMENDATIONS -- Medicare Mission and Quality Assurance -- Quality Assurance Goals of the Medicare Program -- Medicare Program to Assure Quality (MPAQ) -- Public Accountability and Evaluation -- Hospital Conditions of Participation -- Research and Capacity Building -- FUNDING -- ORGANIZATIONAL AND OPERATIONAL FEATURES OF THE MEDICARE PROGRAM TO ASSURE QUALITY -- Starting Points -- Structure -- The Federal and Local Levels -- The Internal Organization-Based Level -- Operational Overview of the Proposed Model -- An Emphasis on Outcomes -- The Importance of the Process of Care -- Continuity of Quality Assessment -- Potential Problems -- IMPLEMENTATION STRATEGY AND PHASES -- Phase I: Years 1 and 2 -- Phase II: Years 2 through 8 -- Data Collection -- Data Analysis Capabilities -- Information Dissemination -- Special Projects -- Phase III: Years 9 and 10 -- CONCLUDING REMARKS -- 1 Health, Health Care, and Quality of Care -- DEFINING QUALITY OF HEALTH CARE -- Elements of the Committee's Definition -- Implications of the Committee's Definition -- HEALTH AND HEALTH CARE IN THE UNITED STATES -- Health and Illness -- Structure of the U.S. Health Care System -- Major Health Policy Issues with Implications for Quality of Care -- Health Care Expenditures -- Access to Services -- Settings of Care -- Integration of Financing and Delivery of Services -- Utilization Management and Utilization Review -- Medicare's Physician Payment System -- Summary -- QUALITY OF HEALTH CARE AS A PUBLIC POLICY ISSUE -- Burden of Harm of Poor Quality.

Assuring Quality: A Professional and a Public Responsibility -- Professional Responsibilities -- Public Sector Responsibilities and Regulation -- Health Care as a Public Good -- Other Forces for Quality Assurance -- Market Forces and Competition -- Malpractice and Risk Management -- Value Purchasing -- Decision Making and Population-Based Outcomes -- SUMMARY -- NOTES -- REFERENCES -- 2 Concepts of Assessing, Assuring, and Improving Quality -- QUALITY ASSESSMENT, QUALITY ASSURANCE, AND QUALITY IMPROVEMENT -- Definitions -- Purposes of Quality Assurance -- Internal and External Programs -- CRITERIA FOR JUDGING AN EFFECTIVE QUALITY ASSURANCE PROGRAM -- QUALITY ASSURANCE CONCEPTUAL MODELS -- The Traditional Structure-Process-Outcome Model -- Structure -- Process -- Outcomes -- Continuous Quality Improvement -- Four Core Assumptions -- Eight Key Constructs -- Applications -- Quality Assurance Concepts from an International Perspective -- TRADITIONAL AND CONTINUOUS IMPROVEMENT MODELS COMPARED -- SUMMARY -- NOTES -- REFERENCES -- 3 The Elderly Population -- SIZE AND GROWTH OF THE ELDERLY POPULATION -- SOCIODEMOGRAPHIC CHARACTERISTICS -- Sex Ratios in the Elderly Population -- Race and Ethnicity of the Elderly Population -- Elderly Support Ratios -- Geographic Distribution of the Elderly Population -- Living Arrangements for the Elderly -- Community Residents -- Nursing Home Residents -- Health Insurance for the Elderly -- ECONOMICS OF AGING -- Elderly Income -- Composition of Income -- Trends in Elderly Income -- USE OF THE HEALTH CARE SYSTEM -- Hospital Services -- Physician Services -- Long Term Care Services -- Nursing Home Care -- Home Health Care -- Community-Based Services -- The Federal Government's Role in Support of the Elderly -- HEALTH STATUS -- Self-Assessment of Health Status -- Life Expectancy -- Mortality -- Chronic Illness and Impairment.

Activity Limitations -- Mental Health -- SUMMARY -- NOTE -- REFERENCES -- 4 The Medicare Program -- STRUCTURE, ELIGIBILITY, AND BENEFIT COVERAGE OF THE MEDICARE PROGRAM -- Hospital Insurance -- Supplementary Medical Insurance (SMI) -- Size of the Medicare-Enrolled Population -- Alternatives to Fee-for-Service Health Care Under the Medicare Program -- Health Maintenance Organizations and Competitive Medical Plans (HMOs and CMPs) -- Medicare Insured Groups -- ADMINISTRATION AND FINANCING OF THE MEDICARE PROGRAM -- Administration -- Financing -- EXPENDITURES OF THE MEDICARE PROGRAM -- National Health Care Expenditures -- Medicare Expenditures -- THE PROSPECTIVE PAYMENT SYSTEM (PPS) -- Medicare-Related Commissions -- QUALITY ASSURANCE IN MEDICARE -- The Utilization and Quality Control Peer Review Organization Program (PRO) -- Conditions of Participation -- Utilization Management -- SUMMARY -- NOTES -- REFERENCES -- APPENDIX A THE MEDICARE CATASTROPHIC COVERAGE ACT OF 1988 -- BENEFITS OF THE MEDICARE CATASTROPHIC COVERAGE ACT -- FINANCING -- REPEAL OF CATASTROPHIC COVERAGE -- APPENDIX B THE MEDICARE DECISION SUPPORT SYSTEM -- 5 Hospital Conditions of Participation in Medicare -- STANDARDS AND CONDITIONS -- Historical Background -- Shift from Capacity Standards to Performance Standards -- Development of the Quality Assurance Condition of Participation -- INSPECTION AND ENFORCEMENT -- Inspection Processes -- Enforcement -- FEDERAL GOVERNMENT'S ROLES AND RESPONSIBILITIES -- Federal Oversight -- Federal Resources -- Administrative Coordination -- CONCLUSIONS -- SUMMARY -- NOTES -- REFERENCES -- 6 Federal Quality Assurance Programs for Medicare -- EXPERIMENTAL MEDICAL CARE REVIEW ORGANIZATIONS -- PROFESSIONAL STANDARDS REVIEW ORGANIZATIONS -- Purpose and Structure -- Aspects of the PSRO Program of Importance to the PRO Program -- Utilization Review.

Profile Analysis -- Quality of Care -- Other Efforts -- Delegation -- Costs -- Additional Aspects of the PSRO Program -- The National Council -- Sanctions and Regulatory Orientation -- Impact of the PSRO Program -- Movement to a New Program -- UTILIZATION AND QUALITY CONTROL PEER REVIEW ORGANIZATIONS (PROS) -- PRO Legislation and Regulations -- PRO Organizational Characteristics -- PRO Contracts -- Third PRO Scope of Work (1988-1990) -- Required Review Activities for Hospital Inpatient Care -- Pre-admission and Pre-procedure Review -- Rural Providers -- Nonhospital Review -- PRO Responses to Quality or Utilization Problems -- Quality Intervention Plan -- Sanctions -- PRO, OIG, and DHHS Responsibilities -- Historical Record of Interventions and Sanctions -- Other Required Activities -- Beneficiary Relations -- Community Outreach -- Provider Relations -- Data Acquisition, Sharing, and Reporting -- Costs -- Quality Review in Medicare HMOs and CMPs -- Limited, Basic, and Intensified Review -- Episodes and Ambulatory Review -- Other Initiatives -- Uniform Clinical Data Set -- Pilot Projects for PROs -- Small Area Variations -- Uniform Needs Assessment -- Monitoring and Evaluating PROs -- PROMPTS-2 -- SuperPRO -- AMPRA 1989 Impact Survey -- CONTROVERSIAL OR PROBLEMATIC ASPECTS OF THE PRO PROGRAM -- Generic Screens -- Inpatient Generic Screens -- Related Approaches -- Home Health Agency Review -- Pre-procedure Review -- Physician Review for Quality of Care -- Peer Review -- Sanctions -- Retention and Strengthening of Sanction Authority -- Denials for Substandard Quality of Care -- Administrative Procedures -- Evaluation -- Issues in HMO and CMP Review -- Records and Case Selection -- Limited Review -- Ambulatory Care Review -- Accountability -- Other Issues Relating to HMO and CMP Review -- CONCLUSIONS ABOUT THE PRO PROGRAM -- SUMMARY -- NOTES -- REFERENCES.

7 Quality Problems and the Burdens of Harm -- INTRODUCTION -- Importance of Poor Technical and Interpersonal Quality -- Importance of Overuse in Quality of Care -- Importance of Underuse in Quality of Care -- Differentiating Problems of Poor Technical Quality, Overuse, and Underuse -- Sources of Information About Burdens of Harm -- EVIDENCE OF PROBLEMS IN TECHNICAL QUALITY OF CARE -- General Evidence of Poor Technical Quality -- Malpractice Data -- Research Evidence -- Disciplinary Actions by State Medical Boards -- Evidence of Poor Technical Quality for the Elderly -- PRO Sanctions and Corrective Actions -- Clinical Research Evidence on Quality of Care for the Elderly -- Beneficiary Complaints -- Evidence About Quality Problems in Home Health Care -- Public Testimony -- EVIDENCE OF OVERUSE -- General Evidence of Overuse -- Small Area Analysis -- Evidence of Overuse for the Elderly -- Clinical Research Studies on Overuse of Services for the Elderly -- Public Hearings, Focus Groups, and Site Visits -- EVIDENCE OF UNDERUSE -- Access -- Underdiagnosis and Undertreatment -- Evidence of Underuse Among the Elderly -- Medicare Data -- Other Research Evidence of Underuse of Services for the Elderly -- Public Hearings, Focus Groups, and Site Visits -- SUMMARY -- NOTES -- REFERENCES -- 8 Settings of Care and Payment System Issues for Quality Assurance -- SETTINGS -- Overview -- The Hospital -- Prevention -- Detection -- Correction -- Ambulatory Care -- Prevention -- Detection -- Correction -- Home Health -- Prevention -- Detection -- Correction -- PAYMENT SYSTEMS -- Fee-for-Service Practice -- Data -- Types of Problems -- Prepaid Capitated Systems -- Data -- Types of Problems -- OTHER SETTING AND SYSTEM FACTORS -- SUMMARY -- NOTES -- REFERENCES -- 9 Methods of Quality Assessment and Assurance -- INTRODUCTION -- Important Attributes of Methods.

PREVENTION OF PROBLEMS.