AHQA report highlights shifting role of PROs
AHQA report highlights shifting role of PROs
PROs well-positioned to partner with hospitals
Physicians and hospitals increasingly have the opportunity to use Medicare peer review organizations (PRO) to measurably improve health care for seniors, according to a report recently issued by the Washington, DC-based American Health Quality Association (AHQA), a not-for-profit association of independent, community-based quality improvement organizations holding Medicare PRO contracts. However, the association contends that while Medicare PROs are well-situated to partner with physicians and hospitals to identify and correct systemic problems in a timely fashion, not all hospitals are fully aware of these opportunities.
To date, many hospitals are more familiar with PROs in the context of the payment error prevention programs they already are required to participate in, according to AHQA’s director of communications Alwyn Cassil. The model for the quality improvement projects is a voluntary nonpunitive collaborative educational model. "What is remarkable is that more than 4,000 hospitals have worked with PROs on quality improvement projects and they do it because they recognize that the PROs are a valuable resource," says Cassil.
About a year ago, the Health Care Financing Administration (HCFA) established a national campaign designed to harness the collective capability of the PROs and the country’s hospitals and physicians to improve care in six critical disease areas: heart attack, breast cancer, diabetes, heart failure, pneumonia, and stroke. To guide quality improvement efforts, HCFA collected information about the care Medicare beneficiaries received in 1997-99 based on 24 clinical indicators in the six targeted disease areas.
Based on the results, which were recently published in the Journal of the American Medical Association, AHQA argues that tremendous opportunities remain to improve care for older Americans. A Measure of Quality: Improving Perfor-mance in American Health Care documents the results of more than 300 community-based projects conducted in 1996-99 by Medicare’s PROs. The pilot projects involved almost 10,000 hospitals and caregivers and fostered improved care for an estimated 16 million Medicare beneficiaries.
AHQA executive vice president David Shulke says many hospitals don’t recognize that 70% of the work performed by the PROs in Medicare is in the area of clinical quality improvement. "Most institutions, or at least the upper echelon at these institutions, don’t know that PROs offer all these services," he contends. In short, Shulke argues that PROs are essentially acting as free consultants to hospitals to help them improve the quality of the care they provide through the use of suggested clinical pathways and analyses of data. He notes that PRO services also include free abstraction of records and a variety of other suggestions and services paid for by Medicare.
Shulke maintains that hospital administrators responsible for the operation of the entire institution are the ones who most frequently are unaware of collaborative efforts already under way, as well as the opportunity for collaboration presented by PROs.
He says that’s because the issues that rise to their level are typically regulatory and financial matters, even though presently those account for only about 20% of the work currently performed by PROs. "That sometimes creates challenges when we are trying to work with the hospital industry on quality issues," Shulke asserts. He adds that many in Congress continue to believe the way to improve the quality of care is to require hospitals to submit incident reports to the Joint Commission.
"We think the most valuable thing that could be done is for there to be more confidential, on-sight real-time review of care and sharing information about best practices," he argues.
Shulke also notes that PROs increasingly are adapting their quality improvement approach with hospitals and physician group practices to the more sophisticated quality improvement tools established by the Institute for Health Care Improvement and other quality improvement organizations.
For example, he says PROs are now abstracting medical records for individual institutions in addition to providing state-level data received from HCFA contractors. "They are actually extracting information for the individual hospitals and sometimes even for the physician group practices." Those practices are then feeding the data back to hospitals and group practices on almost a real-time basis, he adds.
According to Shulke, that means the data might be only two or three months old when they are received.
"The most important development in the near term is more real-time specific feedback on the care that is being provided by the doctors and the nurses and pharmacists," he asserts. "That means there is a greater likelihood that doctors and others will remember the systems they were or were not using, and they are in better positions to work with the PROs to change those systems and improve the care they provide."
Shulke adds that while national data are very useful for hospitals, state-specific data are often even more valuable. Now, he adds, many hospitals and doctors are demanding their own data. "The data that are being fed back by the PROs increasingly are very close to where the care was provided itself," he reports.
Phil Dunn, CEO of the Texas Medical Founda-tion, takes a similar view. He points out that what might be an effective method of improving the delivery of care in one state may not be as effective in another. For example, he notes that New York does not have the same rural health care delivery system as Texas. As a result, patients who suffer from a heart attack in New York may go straight to a tertiary-level hospital, while in Texas they sometimes have to receive care at an intermediary facility first.
Likewise, he says, variations in personal behavior can require different preventive measures among states. For example, the incidence of smoking may be significantly greater in one state compared to another. "There has to be recognition that different processes must be improved in different states because of personal behavior and the way health care is structured in different parts of the country," he argues.
Dunn also agrees that the evolving role of PROs is consistent with HCFA’s shift in emphasis from enforcement to quality improvement. He says that when PROs were focused primarily on performing case review in a retrospective fashion, they were limited to showing that care was not afforded in a timely fashion. With the emphasis on quality improvement, he says, processes can be improved much more rapidly and on a broader scale.
Finally, Dunn says the shift toward improving the quality of care rather than retrospective review is consistent with the shift toward prospective payment throughout the Medicare program.
"In 1984, prospective payment for inpatient care was a radical change," he explains. "Now that we have prospective payment for skilled nursing care and home health agencies as well as hospital outpatient services, I think it is very appropriate that we are trying to address and improve the processes of care that will change the quality of care rather than chase outlier cases."
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