Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: TUESDAY, February 12, 1991 TAG: 9102120213
SECTION: NATIONAL/INTERNATIONAL PAGE: B6 EDITION: METRO
SOURCE: Cox News Service
DATELINE: WASHINGTON LENGTH: Medium
"We have known for a while that we have had a fundamental problem with the way [peer review organizations] do reviews of the HMOs," said Gail Wilensky, head of the Health Care Financing Administration, which oversees Medicare.
Under previous procedures, the records of HMO patients admitted to hospitals were reviewed. But Wilensky said such reviews missed the treatment of patients who were not admitted, but perhaps should have been.
The change, to be phased in this summer in Florida, California and Minnesota - three states with the largest HMO populations - would draw samples from the entire membership of an HMO to determine whether its subscribers were receiving quality care.
The samples will review both hospital inpatient care as well as ambulatory and other forms of care. In addition, it will look at complaints about access to treatment and continue to review deaths not caused by traumatic injury.
Critics say the system of "managed care," under which HMOs are paid a flat rate to care for all patients, may lead them to provide too little care in an effort to maximize profits.
"We want to make sure we can look at the person, then we can judge whether or not there are any quality problems," Wilensky said.
The second Medicare change, a one-year pilot program, will allow doctors in 13 states to know what parameters are used to screen physician bills and determine whether more information is needed before paying the claims.
Doctors have long complained that such screens were "invisible barbed wire," but Medicare officials have worried that if doctors knew the screens, they would raise rates to the level of the screens.
The study was mandated by Congress as part of the budget act last year.
by CNB