PROs playing expanded role in quality of care

Quality of care has taken on a higher profile in a variety of ways, says Alice Gosfield, president of Gosfield and Associates in Philadelphia. Not only is this clearly detailed in the Department of Health and Human Services’ Office of Inspector General’s (OIG) Work Plan, but the involvement of peer review organizations (PRO) is increasing dramatically.

PROs always have had a powerful sanction authority, says Gosfield. PROs, which now are frequently referred to as quality improvement organizations, have retained the authority to recommend sanctions to exclude providers from Medicare. Moreover, their determinations are binding on claims payment agencies.

However, Gosfield says PROs now are moving across all sites of care with specific performance measures. In addition, they review all cases that come under the Emergency Medical Treatment and Active Labor Act statutes and are obligated to review beneficiary complaints that are referred by the regional office. "They are profoundly significant," she asserts.

Changing the name from a peer review organization to a quality improvement organization is more than just semantics, says Phil Dunne, chief executive officer of the Texas Medical Foundation in Austin.

Dunne says that PROs actually have been increasing the emphasis on quality since 1994. "Each series of contracts that we [execute] with CMS has increased the interest in quality," he reports. What often has not been noticed is that PROs are increasing their work in the area of compliance, he adds.

An important area that sometimes is overlooked is documentation, says Dunne. "It has to be documented as to what you did so that we can identify the necessity, the quality, and the correctness of the billing procedure," he explains.

Gosfield says providers should use clinical practice guidelines as the foundation for everything including price, hiring, human resource allocation, and capital budgets. Most importantly, she says if providers document based on clinical practice guidelines, they will eliminate much of the compliance exposure not only with respect to quality but also overutilization, underutilization, false-claims liability, and malpractice liability.

PROs’ interest in quality of care and quality improvement may be growing, but they remain interested in medical necessity as well, Dunne says. "We are still going to be interested in your monitoring and audit functions, looking at one-day stays and same-day readmissions," he says. PROs also will continue to have an interest in assigning patients the correct status and how that is billed to a government program as well as admission necessity and diagnosis-related group projects.

According to Gosfield, regardless of the type of health care enterprise, the role of physicians in this area is imperative. Providers can work on patient safety in terms of hospital or nursing home systems, but the role of physicians remains central. "Doing something that makes the right thing the easy thing to do is critical," she says.

Gosfield says compliance departments all too often function "off to one side" and are not well integrated into the business case for the company. By moving into a more collaborative frame of reference that seeks to use all science available in a standardized and clinically relevant fashion designed to help physicians build effective patient relationships, she says an entirely new culture can be established. "That will help make compliance part of the fundamental mission of any health care organization," Gosfield says.