Medicare

GAO reviewed the quality of care provided to Medicare end-stage renal disease (ESRD) patients, focusing on: (1) accepted performance standards for measuring quality of care provided to ESRD patients; and (2) the quality of care furnished to ESRD patients between providers such as chain-affiliated and unaffiliated dialysis facilities, and between health maintenance organizations (HMO) and providers paid through the standard Medicare ESRD program.

GAO noted that: (1) most experts GAO interviewed and applicable literature GAO reviewed agree that clinical indicators measuring dialysis effectiveness, anemia, and nutritional status-urea reduction ratio, hematocrit levels, and serum albumin levels, respectively-are valid performance indicators for measuring the quality of care ESRD patients receive; (2) these indicators are currently used by the Health Care Financing Administration (HCFA) to evaluate the care furnished to Medicare beneficiaries with ESRD; (3) almost all experts GAO interviewed and applicable literature GAO reviewed also agreed that these indicators were correlated with morbidity and mortality, the ultimate outcome measures; (4) GAO was unable, however, to evaluate the differences between the quality of ESRD care furnished in chain-affiliated and unaffiliated dialysis facilities or the care provided by HMOs and providers in the standard Medicare ESRD program because of limitations with data availability; (5) existing HCFA data about chain affiliation of dialysis facilities is unreliable; (6) when GAO matched ESRD beneficiaries in HCFA's Core Indicators files with HCFA data on ESRD beneficiaries who belong to HMOs, GAO found too few beneficiaries belonging to HMOs in each annual sample to give GAO confidence in the results; (7) even after GAO combined the three annual files, the sample size was too small to permit GAO to make reliable inferences about differences in quality of care between the HMO and non-HMO ESRD populations when comparing beneficiaries with similar characteristics such as age, gender, race, socioeconomic status, and health conditions; (8) if HCFA maintained up-to-date information about the chain affiliations of dialysis facilities and included a larger sample of HMO enrollees in its Core Indicators Project, a comparison could be made of different types of providers and delivery systems that would give GAO confidence in the results; and (9) HCFA program officials agreed and said they would consider collecting data to perform these analyses.