Medicare

Pursuant to a congressional request, GAO examined the Health Care Financing Administration's (HCFA) analysis and use of existing administrative data to monitor the outcome of care received by Medicare patients.

GAO found that HCFA: (1) basically used three analytical approaches for its 1987 Medicare patient outcome analyses, involving 1986 and 1987 data and patient subgroup monitoring over time; (2) strengthened its 1987 analyses regarding patient-level data, clinically coherent diagnostic groups, comorbidity information, and more appropriate illness severity adjustments; and (3) primarily used its outcome analyses to require peer review organizations (PRO) to examine the hospitals the analyses identified as having potential problems. GAO also found that: (1) HCFA contractors used analytical approaches, involving nonintrusive outcomes, a risk-adjusted mortality index, disease staging, and hospital rate-setting, which could enhance data analysis; and (2) other analytical approaches, involving risk-adjusted monitoring and computerized identification of complications, could also enhance data analysis. In addition, GAO found that some of the various approaches: (1) used current Medicare administrative data to better advantage than did others; (2) demonstrated the great potential for identifying types of cases with unusually favorable or adverse outcomes; (3) lacked adequate validation regarding their effectiveness in targeting cases for quality review; (4) lacked capability to analyze any data other than mortality; and (5) did not adequately address the potential deviation or problems caused by random variation, particularly in instances involving only small numbers of cases.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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