Medicare: Private-Sector and Federal Efforts to Assess Health Care
Quality (Testimony, 09/19/96, GAO/T-HEHS-96-215).

GAO discussed the Health Care Financing Administration's (HCFA) efforts
to provide health care quality information to Medicare beneficiaries
joining health maintenance organizations (HMO). GAO noted that: (1)
corporate purchasers use accreditation and performance measurement
monitoring to ensure that HMO furnish quality health care; (2) HCFA is
starting to use similar methods to ensure HMO quality; (3) while the use
of performance measurement indicators has become popular, such
indicators may not be reliable or comparable, and may not be valid
measures of quality; (4) 60 percent of large corporations consider HMO
accreditation status by the National Committee for Quality Assurance
(NCQA), before contracting with HMO; (5) NCQA developed a set of
standardized information on HMO focusing on provider actions, rather
than patient care outcomes; (6) NCQA recently released in draft form a
set of measures based on patient care outcomes; (7) HCFA has joined with
a group of corporate purchasers to develop another set of standardized
outcome measures; (8) HCFA uses a qualification review program similar
to accreditation, along with peer review, to assess health care
organizations' quality; and (9) HCFA does not routinely make quality
assessment information available to Medicare beneficiaries.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  T-HEHS-96-215
     TITLE:  Medicare: Private-Sector and Federal Efforts to Assess 
             Health Care Quality
      DATE:  09/19/96
   SUBJECT:  Managed health care
             Health maintenance organizations
             Health care programs
             Quality assurance
             Institution accreditation
             Health services administration
             Health care cost control
             Patient care services
IDENTIFIER:  Medicare Program
             HCFA HMO Qualification Program
             Medicare Peer Review Program
             NCQA Health Plan Employer Data and Information Set
             
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Cover
================================================================ COVER


Before the Older Americans Caucus
House of Representatives

For Release on Delivery
Expected at 10:00 a.m.,
Thursday, September 19, 1996

MEDICARE - PRIVATE-SECTOR AND
FEDERAL EFFORTS TO ASSESS HEALTH
CARE QUALITY

Statement of William J.  Scanlon, Director
Health Financing and Systems Issues
Health, Education, and Human Services Division

GAO/T-HEHS-96-215

GAO/HEHS-96-215T


(108286)


Abbreviations
=============================================================== ABBREV

  HMO - health
  HCFA - health
  WBGH - health
  PRO - health
  NCQA - health
  HEDIS - health
  CalPERS - health
  FAcct - health
  JCAHO - health

MEDICARE:  PRIVATE-SECTOR AND
FEDERAL EFFORTS TO ASSESS HEALTH
CARE QUALITY
============================================================ Chapter 0

Messrs.  Chairmen, Madam Chairwoman, and Members of the Caucus: 

The Health Care Financing Administration (HCFA) now estimates that
4.3 million Medicare beneficiaries are enrolled in health maintenance
organizations (HMO), and enrollment is growing at a rate of about
100,000 new members per month.  I am pleased to be here today to
discuss ways to ensure that quality of care is furnished to Medicare
beneficiaries joining these HMOs.  Like large private-sector
purchasers of health care, HCFA, which administers Medicare, finds
the potential for cost savings associated with managed care
attractive.  But stakeholders--HCFA, private-sector purchasers, and
others, such as individual consumers--are concerned that the cost
control strategies HMOs use could lead to diminished quality of care. 
As a result, stakeholders are interested in programs that protect
consumers from cost reduction strategies that might adversely affect
their health care. 

Today, I will discuss the following four areas related to quality
assessment: 

  -- quality assessment methods used by large corporate purchasers of
     health insurance from HMOs,

  -- quality assessment methods used by HCFA in administering the
     Medicare HMO Program,

  -- quality assessment methods HCFA plans for the future, and

  -- what both corporate purchasers and HCFA are doing to share the
     information about quality with employees and Medicare
     beneficiaries. 

This statement relies on two of our recent reports, titled Medicare: 
Federal Efforts to Enhance Patient Quality of Care (GAO/HEHS-96-20,
Apr.  10, 1996), Health Care Reform:  "Report Cards" Are Useful but
Significant Issues Need to Be Addressed (GAO/HEHS-94-219, Sept.  29,
1994), and other past reports on related issues.  (A list of related
GAO products appears at the end of this testimony.) We have also
included information drawn from the results of a 1996 report of 384
U.S.  employers surveyed by Watson Wyatt, a benefits consulting
group, and the Washington Business Group on Health (WBGH).\1

In brief, two quality assessment methods--accreditation and
performance measurement monitoring--are used by large corporate
purchasers to ensure that HMOs they contract with furnish quality
care.  Approximately 60 percent of such purchasers consider HMO
accreditation before they contract with the HMO and then require
periodic reaccreditation thereafter.  Approximately 54 percent
continually monitor certain performance indicators such as
immunization rates, mortality from certain procedures, and patient
satisfaction.  Although these strategies are the best available to
date, possible data and other limitations make them less than
perfect, according to recent research. 

Like corporate purchasers, HCFA is now using similar methods to
ensure quality within risk contract HMOs.  First, as part of its HMO
Qualification Program, HCFA performs initial and subsequent reviews
similar to accreditation.  Second, through its Medicare Peer Review
Organization (PRO) Program, HCFA collects and evaluates performance
indicators for certain procedures or diseases to assess HMO
performance.  Although these are reasonable approaches to assessing
quality, we have reported that HCFA has failed to aggressively
enforce legal and regulatory requirements for its risk contract HMOs. 

HCFA is now enhancing its quality assessment methods by strengthening
its collaboration with the private sector to jointly develop better
performance indicators for the health care needs of older Americans. 
Furthermore, HCFA is placing more emphasis on improving the care all
HMOs provide, regardless of their prior performance, rather than
focusing only on the few providing substandard care.  In addition,
HCFA is developing a survey tool to measure beneficiaries'
satisfaction with HMO performance. 

Individual consumers have expressed interest in information
describing the quality of care they might obtain from different HMOs. 
Some corporate purchasers are distributing HMO performance
information to their employees to help them choose the HMO suited to
their needs.  For example, 47 percent distribute patient satisfaction
survey results, 31 percent distribute information about accreditation
status, and almost 6 percent distribute the results of
condition-specific outcome indicators.  Although HCFA does plan to
distribute information to Medicare beneficiaries about plan
performance, the timetable for doing so is uncertain. 


--------------------
\1 Reality Check:  Is Cost Everything?  WBGH and Watson Wyatt
Worldwide (Washington, D.C.:  1996). 


   BACKGROUND
---------------------------------------------------------- Chapter 0:1

Quality in health care is difficult to define because different
stakeholders look for different attributes.  The following
attributes, however, are those that most stakeholders agree define
the concept of quality. 

  -- appropriateness:  providers giving the right care at the right
     time, such as identifying and treating an infection with
     effective medication;

  -- technical excellence:  furnishing the care in the correct way,
     for example, performing open-heart surgery skillfully;

  -- accessibility:  patients being able to get care when needed, for
     example, getting an appointment with a heart specialist when
     symptoms first occur; and

  -- acceptability:  patients' views of their care, such as being
     satisfied with the outcome of surgery or the speed with which
     they get a doctor's appointment. 

Accreditation and analysis of performance indicators are methods for
gauging whether and to what degree quality health care is provided. 
Accreditation does not directly measure quality, however; instead, it
seeks to ensure that organizational systems necessary to attain
quality are in place.  Accreditation, a formal designation granted by
a third party, is usually based on standards that specify the
resources and organizational arrangements needed to deliver good
care.  For example, standards might set forth staff qualifications or
the requirement that an HMO have an effective quality assurance
program.  During an accreditation survey, a survey team reviews an
organization's policies and procedures and visits the provider to
make certain that the standards are being met.  The survey team
discusses the survey findings with appropriate provider officials and
subsequently prepares a written report.  If standards are not being
met, the HMO usually is given time to take corrective action.  If the
HMO does not take action within a specified time period, it could
lose its accreditation. 

Performance indicators more directly measure the attributes of
quality than does accreditation.  Performance indicators frequently
measure appropriateness and technical excellence--providers'
actions--and the outcomes of those actions.  For example, these
indicators provide information about the rate at which certain
preventive health care actions are furnished, the mortality rate from
certain procedures, or patient satisfaction survey results. 
Administrative databases, medical records, and patient surveys
provide data for measuring these indicators.  The results are then
compared with preestablished benchmarks or with the performance of
other HMOs. 

Historically, health care providers considered confidential the
specific information in an accreditation report and the results of
performance indicators.  Such information was rarely distributed to
purchasers and the general public.  Since the mid-1980s, however,
some large corporate purchasers have been requiring HMOs to furnish
this information before contracting or renewing their contract.  Some
individual consumers are also requesting information on health plans
to help them make their health care purchasing decisions. 


      QUALITY ASSESSMENT METHODS
      HAVE LIMITATIONS
-------------------------------------------------------- Chapter 0:1.1

Some purchasers believe that the standards required to be met for
accreditation might have no bearing on whether quality of care is
actually furnished.  Others view accreditation requirements as a way
of ensuring that systems expected to result in quality care are in
place.  Because accreditation standards do not directly measure
quality, however, many purchasers use a combination of accreditation
and an analysis of performance indicators, including outcomes. 

Although the use of performance indicators to assess quality has
become popular, they present the following problems: 

  -- Information reported about performance may be unreliable.  Data
     sources for performance indicators range from large computerized
     administrative databases maintained by HMOs to individual
     patient medical records kept in providers' offices.  These
     sources may be inaccurate, incomplete, or misleading, however,
     because most administrative databases were designed for
     financial--not clinical--purposes, and providers may knowingly
     or unknowingly place incorrect information in medical records or
     not document certain interventions. 

  -- Indicators may not be valid measures of quality.  Indicators
     measuring organizations' structures and providers' actions are
     often used when assessing quality because they are relatively
     easy to measure.  Research has not clearly demonstrated
     correlations, however, between some common indicators and
     quality of care.  For example, the rate of hospital-
     acquired infections has for a long time been almost universally
     used as an indicator of hospital quality of care.  Many studies
     show a strong link between such infections and increased
     morbidity and mortality.  However, the relationship between this
     infection rate and the quality of care in the hospital is
     unclear.  The risk of acquiring an infection in the hospital may
     be more closely related to patient factors such as underlying
     disease, severity of illness, age, and sex. 

  -- The reason for a given outcome may be difficult to determine. 
     Risk adjustment systems have not been perfected, and tests of
     systems that are in place indicate that they may not be
     reliable.  Outcome measures should be adjusted so that
     differences can be attributed to either the quality of care
     furnished or to patient characteristics such as age, behavior,
     or the presence of other diseases.  If such adjustments are not
     made, providers may contend that poor outcomes are due to their
     caring for sicker patients. 

  -- Performance indicators may not be comparable.  Nationwide
     standards for defining and calculating indicator results have
     not been established.  While relying to some extent on several
     standard indicators, many health plans continue to use their own
     criteria for collecting data and computing results. 
     Consequently, purchasers cannot systematically compare health
     plans to determine which one meets their needs. 


   CORPORATE PURCHASER QUALITY
   ASSESSMENT METHODS
---------------------------------------------------------- Chapter 0:2

Cost continues to be an overriding concern to virtually all corporate
purchasers.  However, many large corporate purchasers are using
accreditation status and information about specific quality-of-care
performance indicators to determine which HMO(s) to offer their
employees.  According to a recent survey of 384 U.S.  employers
conducted by Watson Wyatt, a benefits consulting organization, and
WBGH, 60 percent of large corporations\2 consider accreditation
status by the National Committee for Quality Assurance (NCQA) when
deciding to purchase health insurance from an HMO.\3 Nineteen percent
also consider accreditation from other organizations.  Furthermore,
some purchasers evaluate other organizational structures.  For
example, 55 percent said they evaluate whether a health plan has
quality improvement initiatives, and 67 percent determine that the
health plan ensures that its providers are qualified. 

Some large purchasers also use the results of specific performance
indicators to track providers' actions or their performance outcomes. 
In the early 1990s, corporate purchasers, interested in
accountability and buying quality health care, started to request
specific information about HMOs' performance.  The Health Plan
Employer Data and Information Set (HEDIS), developed under the
auspices of NCQA in 1993, was a major attempt to collect standardized
information on quality of care furnished by HMOs.  These first HEDIS
indicators of HMO activities addressed quality, access and patient
satisfaction, membership and utilization, finance, and HMO
management.  The indicators addressing quality issues generally
focused on providers' actions and not the outcomes of those actions. 
For example, the rate women received a mammography exam is calculated
but not the 5-year survival rate of women diagnosed with breast
cancer.  According to the Watson Wyatt/WBGH survey, 54 percent of
large employers use HEDIS to help gauge the quality of care provided
by health plans, and 68 percent evaluate the results of consumer
satisfaction surveys. 

NCQA recognized the need for outcome indicators when it released its
first HEDIS measures.  In July 1996, it released for public comment a
new draft version of 75 HEDIS measures based on the recommendations
of purchasers, HCFA, and other stakeholders.  This new version, which
NCQA expects will be used by health plans in 1997, includes a
revision of prior HEDIS indicators, a standardized patient
satisfaction survey, and more indicators for high-prevalence
diseases.  The clinical care measures continue to focus on providers'
actions, however, rather than outcomes.  NCQA also released another
30 indicators, a few focusing on outcomes.  NCQA defines these
indicators as a "testing set" to be used by health plans only after
evidence has been established that certain criteria are met, such as
that the indicator is a valid measure of what it is intended to
assess. 

While NCQA was developing new HEDIS measures, a large group of
corporate purchasers and HCFA established the Foundation for
Accountability (FAcct) to develop standardized outcome measures.  In
early fall 1996, the Foundation released eight indicators for
treating diabetes, breast cancer, and major depression.  Some of
these measures focus on outcomes.  The Foundation also endorsed an
indicator addressing consumers' satisfaction with health plans. 

Xerox, a large corporate purchaser, provides an example of a
purchaser's use of quality assessment methods.  Xerox's stated
objective is to increase the accountability of health plans
contracting with it and to improve the health status of its
employees.  Xerox officials review health plan reports about the
plan's accreditation status, results on HEDIS performance indicators,
access to services, and membership satisfaction.  Reports also
include goals for each measure as benchmarks.  Xerox's goal is to
develop long-term relationships with health plans.  To this end,
Xerox encourages health plans' continuous improvement rather than
immediately terminating a contract if a plan does not meet specific
performance goals. 


--------------------
\2 A large corporation is defined by the survey authors as one that
has 10,000 or more employees.  One hundred twenty-three large
corporations responded to this survey. 

\3 NCQA accredits only HMOs.  Other organizations accredit managed
care organizations that are not HMOs. 


      CONTINUOUS QUALITY
      IMPROVEMENT
-------------------------------------------------------- Chapter 0:2.1

In addition to assessing performance, some large purchasers require
that HMOs with which they contract focus on continuous quality
improvement.  Under this approach, attempts are made to identify and
establish excellent care by focusing attention on inappropriate
variation in the quality of care furnished to identified populations
and eliminating the variations.  This approach tries to consistently
improve all plans' performance, regardless of prior performance.  In
the past, quality assurance programs focused on the care provided to
individual patients, directing improvement activities toward
individual "outlier" providers rather than encouraging improvement by
health care providers.  These efforts were limited to a small number
of providers and often resulted in adversarial relations between the
reviewers and those being reviewed. 


   HCFA'S QUALITY ASSESSMENT
   METHODS FOR MEDICARE RISK
   CONTRACT HMOS
---------------------------------------------------------- Chapter 0:3

Like other large corporate purchasers, HCFA uses an inspection
process and analysis of performance indicators to evaluate the
quality of care provided to Medicare beneficiaries in risk contract
HMOs.  HCFA's HMO Qualification Program is intended to ensure that
HMOs with Medicare contracts meet minimum requirements for
organizational structures and processes.  HCFA's Medicare PRO Program
is intended to measure an HMO's performance by evaluating indicators
for selected diseases or procedures of concern to older Americans. 


      HMO QUALIFICATION PROGRAM
-------------------------------------------------------- Chapter 0:3.1

Like accreditation, HCFA's HMO Qualification Program is an inspection
method.  HCFA's initial approval of an HMO to serve Medicare
beneficiaries includes this inspection.  Thereafter, HCFA personnel
visit contracting HMOs at least once every 2 years to monitor their
compliance with requirements.  HCFA's inspection team spends several
days at the HMO comparing the HMO's policies and procedures with
Medicare requirements.  The team informs the HMO of its preliminary
findings at the end of the visit and later prepares a formal report. 
If the HMO has failed to meet one or more requirements, it must
submit a corrective action plan, including a timetable for correcting
the deficiency.  HCFA personnel may revisit the site to monitor
compliance at the end of the time period specified in the plan's
timetable or may simply require regular progress reports.  If the HMO
fails to correct the deficiency in a timely manner, HCFA may
terminate its contract or, under some circumstances, impose a civil
monetary penalty or suspend Medicare enrollment.\4 This happens
rarely, however, and only after repeated HCFA efforts to get the HMO
to correct the deficiencies. 

In the past, we have criticized HCFA for failing to aggressively
enforce Medicare's HMO Qualification Program.  In 1988 and again in
1991, we found that HCFA's efforts to obtain corrective action from a
few noncompliant HMOs were mainly ineffective, even though HCFA
repeatedly requested such action.\5

Furthermore, HCFA often found that the same problems existed when it
made its next annual monitoring visit.  In our August 1995 report, we
found the same problems.\6 We concluded that HCFA's HMO Qualification
Program is inadequate to ensure that Medicare HMOs comply with
standards for ensuring quality of care.  Specifically, this program
remains inadequate because HCFA does not

  -- determine if HMO quality assurance programs are operating
     effectively,

  -- systematically incorporate the results of PRO review of HMOs or
     use PRO staff expertise in its compliance monitoring, and

  -- routinely collect utilization data that could most directly
     indicate potential quality problems. 

We also found that the enforcement processes are still slow when HCFA
does find quality problems or other deficiencies at HMOs that do not
comply promptly with federal standards.  For example, even though one
HMO repeatedly did not meet standards during a 7-year period and HCFA
received PRO reports indicating that the HMO was providing
substandard care to a significant number of beneficiaries, HCFA
allowed the HMO to operate as freely as a fully compliant HMO. 


--------------------
\4 The Health Insurance Portability and Accountability Act of 1996
(P.L.  104-191) generally broadened the circumstances under which
HCFA may apply civil money penalties and suspension of enrollment. 
These changes are effective in contract years beginning on or after
January 1, 1997. 

\5 Medicare:  Experience Shows Ways to Improve Oversight of Health
Maintenance Organizations (GAO/HRD-88-73, Aug.  17, 1988) and
Medicare:  HCFA Needs to Take Stronger Actions Against HMOs Violating
Federal Standards (GAO/HRD-92-11, Nov.  12, 1991). 

\6 Medicare:  Increased HMO Oversight Could Improve Quality and
Access to Care (GAO/HEHS-95-155, Aug.  3, 1995). 


      MEDICARE PRO PROGRAM
-------------------------------------------------------- Chapter 0:3.2

Like large corporate purchasers' analysis of performance indicators,
the Medicare PRO Program analyzes HMO performance treating certain
diseases or performing selected procedures.  The PRO Program,
however, is substantially changing its approach. 

Historically, the PROs examined both inpatient and outpatient medical
records of a random sample of beneficiaries to identify and correct
substandard providers.  If the PRO found indications of poor
practice, it contacted the responsible provider to give it the
opportunity to explain these circumstances.  If the PRO found
continuing problems and the provider would not or could not correct
an identified poor practice, the PRO could recommend that the
Department of Health and Human Services' Office of the Inspector
General impose a sanction ranging from development of a corrective
action plan to suspension of eligibility to receive reimbursement
from Medicare.  This PRO Program was criticized by providers and
other health care experts because relatively few substandard
providers were identified; HCFA officials found this model to be
confrontational, unpopular with the physician community, and of
limited effectiveness. 

Therefore, by the end of 1995, case reviews had been replaced by
cooperative projects modeled on continuous quality improvement
concepts implemented by mutual agreement between PROs and risk
contract HMOs.\7 Provider participation is voluntary.  Typically,
these cooperative projects involve establishing joint identification
of a problem, appropriate performance indicators, and benchmarks. 
The PRO then measures current HMO performance on these indicators and
disseminates these data to the HMOs.  HMOs then may choose to
participate in the project to improve care.  After implementation of
corrective action, the PROs again collect data to determine if
improvements have been made. 

Although this process is voluntary, HCFA officials say that they
believe most HMOs will welcome the opportunity to collaborate on
projects that can improve the quality of care.  They do not believe
that provider noncooperation will be a significant problem.  HCFA
officials told us, however, that they still can take action if they
have strong indications that an HMO has significant quality-of-care
problems.  If an HMO refuses to cooperate, HCFA can still apply a
range of sanctions, including a letter terminating the HMO's
participation. 

In one state, we talked with HMO and PRO officials about this new
approach.  The HMOs liked it, particularly the fact that the PRO
provided them with comparative performance data that would be
otherwise unavailable to them.  PRO officials also felt that this
program was more successful than case review because it addressed the
care being provided to the majority of beneficiaries rather than the
1 or 2 percent who may be recipients of bad care.  Although we think
this new approach holds promise, it is too early to evaluate its
impact.  But an evaluation of this program as soon as feasible is
essential because it is such a major departure from previous PRO
practice. 


--------------------
\7 Individual case review continues only for a few mandatory
categories such as beneficiary complaints of poor quality care,
potential cases of grossly poor care or unnecessary admissions
identified during project data collection, and notices of noncoverage
issued by hospitals or managed care plans. 


   NEW HCFA QUALITY ASSESSMENT
   INITIATIVES
---------------------------------------------------------- Chapter 0:4

To minimize the administrative burden on health plans and develop
more valid, reliable, and comparable performance measures, HCFA is
collaborating with private-sector purchasers to develop standardized
performance indicators.  HCFA also plans to collect data on
beneficiaries' satisfaction with risk contract HMOs. 


      DEVELOPMENT OF PERFORMANCE
      MEASURES
-------------------------------------------------------- Chapter 0:4.1

In June 1995, HCFA announced that it was joining FAcct.  According to
HCFA, it has played a major role in developing the Foundation's
performance indicators for depression, breast cancer, and diabetes. 
Furthermore, HCFA worked with NCQA on its new HEDIS indicators.  HCFA
played a role in identifying and defining seven newly released
indicators that measure functional status for enrollees over age 60,
mammography rates, rate of influenza vaccinations, rate of retinal
examinations for diabetics, outpatient follow-up after acute
psychiatric hospitalization, utilization of certain appropriate
medications in heart attack patients, and smoking cessation programs. 

HCFA also plans to conduct a survey of Medicare beneficiaries
enrolled in managed care.  It is developing a survey instrument in
cooperation with the Agency for Health Care Policy and Research. 
Data collected in this survey will include information on member
satisfaction, perceived quality of care, and access to care.  HCFA
officials told us that they plan to have an outside contractor
perform annual surveys of a statistically valid sample of Medicare
enrollees in every HMO with a Medicare contract.  The contractor will
use a standard survey and provide a consistent analysis of the
information received from beneficiaries. 


   DISSEMINATING QUALITY
   ASSESSMENT RESULTS TO EMPLOYEES
   AND MEDICARE BENEFICIARIES
---------------------------------------------------------- Chapter 0:5

Some large corporate purchasers are sharing performance assessment
information with their employees.  They believe that individual
employees can better choose health plans if they have good
information on which to base their enrollment decisions.  According
to the Watson Wyatt/WBGH survey, 31 percent of large corporate
purchasers give their employees information about accreditation
status, 25 percent give their employees information about overall
health plan performance, 13 percent give their employees HEDIS
information, and 47 percent distribute consumer satisfaction survey
results.  Additionally, 32 percent of the large purchasers surveyed
offer financial incentives to their employees to choose plans that
they have designated as being of "exceptional quality."

The California Public Employees' Retirement System (CalPERS) is an
example of a large purchaser providing performance information to
individuals to help them select a plan that meets their needs. 
Although it had furnished some comparative information to its
employees in previous years, that information generally featured
premium and benefits coverage.  CalPERS' May 1995 Health Plan
Quality/Performance Report was its first effort to distribute
comprehensive information that includes both specific performance
indicators about quality and member satisfaction results.  The
quality performance data are based on HEDIS indicators measuring HMO
success with providing childhood immunizations, cholesterol
screening, prenatal care, cervical and breast cancer screening
results, and diabetic eye exams.  Employee survey results include
employee satisfaction with physician care, hospital care, the overall
plan, and the results of a question asking whether members would
recommend the plan to a fellow employee or friend.  CalPERS released
a new report providing updated information in 1996. 

Although HCFA collects performance information that could be useful
to beneficiaries, it does not routinely make such information
available to them nor does it have immediate plans to do so.  HCFA
does not distribute the results of its HMO Qualification Program nor
does it distribute information it collects about Medicare HMO
enrollment and disenrollment rates, Medicare appeals, beneficiary
complaints, plan financial condition, availability of and access to
services, and marketing strategies.  However, HCFA officials have
told us they are considering ways to provide Medicare beneficiaries
with information that will help them choose managed care plans.  HCFA
is working to make comparative information available on the Internet. 
Phase one of this project, to be implemented in 1997, will provide
comparative data about HMO benefits, premiums, and cost-sharing
requirements.  Later phases will add information on the results of
plan member satisfaction surveys and, eventually, outcome indicators. 
No timetable has been established, however, for disseminating the
latter information. 


-------------------------------------------------------- Chapter 0:5.1

In conclusion, large corporate purchasers who rely on experts in the
field are the leaders in health care quality assessment.  Although
HCFA's current quality assessment programs are catching up with those
of large corporate purchasers, some areas need further improvement. 
Most notably, HCFA still lags behind the private sector in
disseminating performance assessment information to its
beneficiaries. 

Messrs.  Chairmen and Madam Chairwoman, this concludes my formal
remarks.  I will be happy to answer any questions from you and other
members of the Caucus. 


   CONTRIBUTORS
---------------------------------------------------------- Chapter 0:6

For more information on this testimony, please call Sandra K. 
Isaacson, Assistant Director, at (202) 512-7174.  Other major
contributors include Peter E.  Schmidt. 



RELATED GAO PRODUCTS
=========================================================== Appendix 1

Health Care:  Employers and Individual Consumers Want Additional
Information on Quality (GAO/HEHS-95-201, Sept.  29, 1995). 

Medicare:  Increased HMO Oversight Could Improve Quality and Access
to Care (GAO/HEHS-95-155, Aug.  3, 1995). 

Medicare:  Enhancing Health Care Quality Assurance
(GAO/T-HEHS-95-224, July 27, 1995). 

Community Health Centers:  Challenges in Transitioning to Prepaid
Managed Care (GAO/HEHS-95-138, May 4, 1995); testimony on the same
topic (GAO/T-HEHS-95-143, May 4, 1995). 

Medicare:  Opportunities Are Available to Apply Managed Care
Strategies (GAO/T-HEHS-95-81, Feb.  10, 1995). 

Health Care Reform:  "Report Cards" Are Useful but Significant Issues
Need to Be Addressed (GAO/HEHS-94-219, Sept.  29, 1994). 

Home Health Care:  HCFA Properly Evaluated JCAHO's Ability to Survey
Home Health Agencies (GAO/HRD-93-33, Oct.  26, 1992). 

Home Health Care:  HCFA Evaluation of Community Health Accreditation
Program Inadequate (GAO/HRD-92-93, Apr.  20, 1992). 

Medicare:  HCFA Needs to Take Stronger Actions Against HMOs Violating
Federal Standards (GAO/HRD-92-11, Nov.  12, 1991). 

Health Care:  Actions to Terminate Problem Hospitals From Medicare
Are Inadequate (GAO/HRD-91-54, Sept.  5, 1991). 

Medicare:  PRO Review Does Not Ensure Quality of Care Provided by
Risk HMOs (GAO/HRD-91-48, Mar.  13, 1991). 

Medicare:  Physician Incentive Payments by Prepaid Health Plans Could
Lower Quality of Care (GAO/HRD-89-29, Dec.  12, 1988). 

Medicare:  Experience Shows Ways to Improve Oversight of Health
Maintenance Organizations (GAO/HRD-88-73, Aug.  17, 1988). 

Medicare:  Issues Raised by Florida Health Maintenance Organization
Demonstrations (GAO/HRD-86-97, July 16, 1986). 


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