Medicare Quality of Care

The oversight of end-stage renal disease (ESRD) facilities needs improvement. Increasing the budget of the Health Care Financing Administration (HCFA) for inspecting ESRD facilities should help improve oversight, as would putting some teeth into the enforcement process. One way to give facilities more incentives to stay in compliance with Medicare reimbursement policies would be to have available the kinds of monetary penalties that can be used when nursing homes are found to have severe or repeated serious deficiencies. For example, HCFA can fine nursing homes, and the fines are not forgiven when the facility corrects its problems. Another way to strengthen oversight would be for state agencies and ESRD's networks to share information on complaints and known quality-of-care problems at specific facilities. This would help target inspection resources where they are most needed. HCFA's efforts to use available outcome data for targeting its survey efforts might also eventually help in this regard, but more testing and evaluation are needed to help ensure that the data used are sufficient to predict noncompliance with Medicare's quality standards. GAO summarized this report in testimony before Congress; see: Medicare Quality of Care: Oversight of Kidney Dialysis Facilities Needs Improvement, by William J. Scanlon, Director of Health Financing and Public Health Issues, before the Senate Special Committee on Aging. GAO/T-HEHS-00-136, June 26 (7 pages).

GAO noted that: (1) over the past 7 years, the number of HCFA-funded inspections of dialysis facilities has declined significantly; (2) these unannounced inspections, commonly called surveys, which are HCFA's primary tool for ensuring that facilities meet standards protecting patients' health and safety, were conducted at only 11 percent of the dialysis facilities eligible for recertification in 1999, compared with 52 percent in 1993; (3) when such surveys were conducted they, showed that noncompliance is a problem; (4) to enable more frequent surveys, HCFA has requested a threefold increase in funding for on-site inspections in its budget request for fiscal year 2001; (5) this funding level would support a survey of all dialysis facilities every 3 years; (6) while increasing on-site surveys will likely encourage more facilities to improve conditions, the enforcement system provides little assurance that corrections will be sustained; (7) essentially, HCFA's only current enforcement tool is to terminate a facility from the Medicare program if it does not correct its deficiencies; (8) the threat of termination brings nearly all facilities into compliance for a while, but they do not necessarily stay that way; (9) in every state GAO visited, GAO found instances in which facilities that had corrected their problems were found to have serious problems shortly afterward; (10) Congress has authorized HCFA to use other enforcement tools, such as the denial of payment for Medicare services, but HCFA maintains that this authority would have limited effectiveness and applicability; (11) HCFA is planning to use clinical and outcome data more extensively in deciding which facilities to survey and monitor more closely; (12) although the information HCFA intends to use may help in that regard, it has limitations as well; and (13) these data are designed to give a picture of the care being provided to end-stage renal disease (ESRD) patients generally, but they are often not current, detailed, or reliable enough to detect specific facilities that are providing substandard services.

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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