The return of the Medicare police? Return of claims review? BD
Reviving the punitive aspects of the PROs but abandoning the actual peer review element would create an unregulated enforcement entity that wouldn't follow the QIO directive to use the least intrusive methods to solve quality problems, said Jonathan Sugarman, MD, MPH. He's the president and CEO of Qualis Health, the QIO serving Idaho and Washington. "They used to call them the Medicare police. Now maybe it's the Medicare militia," he said. "It's based on the theory that enforcement and punishment are the best ways to improve care to Medicare beneficiaries, and that's not really consistent with contemporary understanding of quality improvement." Dr. Sugarman noted that Gail Wilensky, PhD, Medicare's administrator from 1990 to 1992, often described PROs as "the most hated program in HHS." Doctors complained that the organizations would comb through claims data -- often years old -- and find that physicians had done something wrong, but the PROs wouldn't give them any idea of what to do about it. Physicians who already are losing patience with Medicare for other reasons will become even more fed up if the old, much-despised case review system is resurrected, he said.
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