Medicare

In response to a congressional request, GAO examined Medicare's quality-of-care review systems to determine: (1) the options for short-term improvements in measuring the quality of care; and (2) a framework for considering broader, long-term issues related to the measurement and monitoring of the quality of care.

GAO found that the Health Care Financing Administration (HCFA) does not have: (1) an organization with the overall responsibility for assessing the quality of care provided in different care settings and for evaluating changes in levels of quality over time; (2) a review organization for developing, coordinating, or disseminating information about methods for assessing quality; and (3) a mechanism for incorporating the best methods and medical judgment from the medical community into Medicare quality assurance activities. GAO identified four possible short-term options, including: (1) adding uniformly coded diagnostic data to the Medicare data system; (2) producing information on the validity and effectiveness of current screening to identify quality-of-care problems and to profile provider performance; (3) evaluating quality-of-care reviews in order to provide comparative information on the effectiveness of quality reassessment methods in different settings; and (4) using inspection data to generate nationwide information on the needs of Medicare patients in subacute settings and the quality of care they receive. GAO also identified three strategies that would require a longer time frame, including: (1) better integration of the data collection and monitoring responsibilities of Medicare claims processors and review organizations; (2) the incorporation of reliable medical record review methodologies into peer reviews; and (3) the creation of epidemiological databases.