Division of National Cost Estimates, Office of the Actuary, Health Care Financing Administration. “National Health Expenditures, 1986–2000”. Health Care Financing Review 8(4):1–36, 1987; Committee on Ways and Means, U.S. Congress, House of Representatives. Background Material on Programs Within the Jurisdiction of the Committee on Ways and Means. Washington: U.S. Government Printing Office, March, 1989.Google Scholar

For a recent examination of utilization management, see Institute of Medicine. Controlling Costs and Changing Patient Care? The Role of Utilization Management. Gray, B.H. and Field, M.J., eds. Washington, DC: National Academy Press, 1989. The Institute of Medicine currently is conducting two studies on practice guidelines; the final report of one study being done for the Forum on Quality and Effectiveness in Health Care of the Agency for Health Care Policy and Research will be released in mid-1990 (Institute of Medicine. Clinical Practice Guidelines: Directions for a New Program. Field, M.J. and Lohr, K.N., eds. Washington, DC: National Academy Press, 1990).Google Scholar

For instance, the United States ranks among the top ten countries in life expectancy for persons who have attained age 65—almost 15 additional years for men and almost 19 for women. See National Center for Health Statistics, Public Health Service, U.S. Department of Health and Human Services. Health United States 1989. Washington, DC: U.S. Government Printing Office, forthcoming.Google Scholar

Institute of Medicine. Medicare: A Strategy for Quality Assurance. Lohr, K.N., ed. Volumes I and II. Washington, DC: National Academy Press, 1990. See also: Lohr, K.N. and Schroeder, S.A. “Special Report. A Strategy for Quality Assurance in Medicare.” New England Journal of Medicine, 1990, 322:707–712. The proceedings of an invitational conference held in May 1990 to explore further the IOM committee's findings and recommendations will be published as New Directions for Medicare Quality Assurance: Proceedings of a Conference. Lohr, K.N., Donaldson, M.S. and Harris-Wehling, J., eds. Washington, DC: National Academy Press, forthcoming.CrossRefGoogle Scholar

The methods and results of these two sets of focus groups are described in Walker, A.J., “Results of the Medicare Beneficiary and Physician Focus Groups”. Pp. 35–90 in Medicare: A Strategy for Quality Assurance. Volume II. Sources and Background Materials. Lohr, K.N., ed. Washington, DC: National Academy Press, 1990.Google Scholar

The methods and results of the public hearings and written testimony analysis are described in Harris-Wehling, J. “Oral and Written Testimony from the Public Hearings.” Pp. 7–34 in Medicare: A Strategy for Quality Assurance. Volume II. Sources and Background Materials. Lohr, K.N., ed. Washington, DC: National Academy Press, 1990.Google Scholar

Three of those papers will be published by the Health Administration Press in a forthcoming monograph: R.H. Palmer on definitions of quality of care; A. Donabedian on barriers to quality assurance; and G. Povar on bioethical aspects of quality assurance.Google Scholar

The methods and results of the site visits analysis are described in Donaldson, M.S. and Lohr, K. N.. “Site Visits.” Pp. 91–115 in Medicare: A Strategy for Quality Assurance. Volume II. Sources and Background Materials. Lohr, K.N., ed. Washington, DC: National Academy Press, 1990.Google Scholar

See, for instance: Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Hospitals, 1990. Chicago, Ill: Joint Commission, 1989; Office of Technology Assessment. The Quality of Medical Care. Information for Consumers. OTA-H-386. Washington, DC: Congress of the United States, Office of Technology Assessment, June 1988. The background to the IOM's definition is more fully discussed in Harris-Wehling, J. “Defining Quality of Care”. Pp. 116–139 in Medicare: A Strategy for Quality Assurance. Volume II: Sources and Background Materials. Lohr, K.N., ed. Washington, DC: National Academy Press, 1990.Google Scholar

Donabedian, A., “Evaluating the Quality of Medical Care”, Milbank Memorial Fund Quarterly, 1966, 44:166–203 July (Part 2); Donabedian, A., Explorations in Quality Assessment and Monitoring. Volumes I – III. Ann Arbor, Mich.: Health Administration Press, 1982, 1984, 1985.Google Scholar

Berwick, D.M., “Sounding Board. Continuous Improvement as an Ideal in Health Care”, New England Journal of Medicine, 1989, 320: 53–56; Batalden, P.B. and Buchanan, E.D., “Industrial Models of Quality Improvement, in Providing Quality Care: The Challenge to Physicians. Goldfield, N. and Nash, D.B., eds. Philadelphia: American College of Physicians, 1989.Google Scholar

For an early discussion of the PRO program, see Dans, P.E., Weiner, J.P. and Otter, S.E., “Peer Review Organizations: Promises and Pitfalls.” New England Journal of Medicine, 1985, 313:1131–1137. K. N. Lohr, in Peer Review Organizations: Quality Assurance in Medicare. P-7125, Santa Monica, CA: The RAND Corporation, 1985, describes the lengthy implementation of the PRO program with special emphasis on its quality of care dimensions. The IOM report on this study (cited in Note No. 3) deals extensively with the PRO program, especially in Chapter 6 of Volume I and Chapter 8 of Volume II.CrossRefGoogle Scholar

Those tasks include generic quality screening conducted by nurse reviewers, who can determine that a case passes the screens. If a case fails any screen and has a potential quality problem, then it must be referred to a physician advisor for further evaluation; only the physician advisor can “confirm” a quality problem. Discharge review is intended to flag problems with premature discharge when the patient was not medically stable at discharge or when discharge was not consistent with the patient's continued need for acute inpatient care. Retrospective admission review identifies whether inpatient hospital care was medically necessary and appropriate, by reviewing reasons for admission against pre-established criteria devised or adopted by individual PROs. Invasive procedure review retrospectively examines the medical necessity of invasive procedures that affect the assignment of a case to one DRG rather than another. Depending on whether the entire admission or just the procedure is considered unjustified, payment for all of the admission or the procedure may be denied. DRG validation assures that cases are accurately classified for Medicare payment under PPS, and coverage review determines whether items or services normally excluded from Medicare coverage are medically necessary and thus covered. Chapter 6, Volume I and Chapter 8, Volume II of the IOM report (see Note No. 4) describe these and other required PRO activities in greater detail.Google Scholar

See Jost, T., Administrative Law Issues Involving the Medicare Utilization and Quality Control Peer Review Organization (PRO Program: Analysis and Recommendations. Report to the Administrative Conference of the United States. Washington, DC: Administrative Conference, November 8, 1988, reprinted in Ohio State Law Journal 1989; 50(1).Google Scholar

Among the important developments occurring while the IOM study was in progress was the creation of the Agency for Health Care Policy and Research (AHCPR) in the U.S. Public Health Service (by the Omnibus Budget Reconciliation Act of 1989). In addition to traditional concerns of health services research addressed by its predecessor agency, the National Center for Health Services Research, AHCPR has considerably expanded responsibilities for supporting the development, dissemination, and evaluation of practice guidelines and for conducting research in the area of effectiveness of medical care and outcomes of care.Google Scholar