Medicare

PRO Review Does Not Assure Quality of Care Provided by Risk HMOs Gao ID: HRD-91-48 March 13, 1991

Pursuant to a congressional request, GAO reviewed the: (1) Health Care Financing Administration's (HCFA) management of peer review organization (PRO) reviews of risk health maintenance organizations (HMO); (2) PRO review of the internal quality assurance programs at risk HMO; and (3) PRO external review of health care provided by risk HMO.

GAO found that: (1) effective internal quality assurance programs (QAP) for at-risk HMO were essential, since they were the first line of defense for protecting Medicare enrollees against substandard health care; (2) HCFA did not comprehensively assess QAP effectiveness because it focused on structure rather than effectiveness, and made PRO reviews of HMO QAP optional; (3) some HMO QAP did not have the capacity to identify and correct quality problems; (4) HCFA continued to rely on deficient QAP to correct serious quality problems; (5) the PRO external review process was hampered by such chronic sampling problems as incomplete information on HMO inpatient hospital enrollees, unreliable results from the current HCFA inpatient care sampling plan, and limited ambulatory reviews; and (6) HCFA was not using results of PRO reviews in its HMO oversight activities.

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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