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OIG report hits PROs for putting doctors above beneficiaries

The Office of Inspector General calls for an overhaul of Medicare's system for dealing with patient complaints.

By Markian Hawryluk, amednews staff. Sept. 3, 2001.

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Washington -- A new report on the Medicare beneficiary complaint process has renewed debate over whether peer review organizations should be coaches or cops, pitting the rights of physicians against the rights of consumers.

The report by the Dept. of Health and Human Services' Office of Inspector General found that PROs were not an effective beneficiary complaint system -- they rarely reported their findings to complainants or initiated any intervention beyond a letter to the involved doctor for substantiated complaints. The OIG attributed some of the shortcomings to PROs' desire to maintain a good working relationship with physicians and other health professionals to maximize their quality improvement initiatives.

"PROs traditionally have exhibited a reluctance to take on a more enforcement-oriented role that might undermine their relationships with the medical community," the OIG said. In the past five years, PROs have referred only six physicians or facilities for sanction, and none in the past two years.

The AMA said the complaint process could be improved to be more responsive to patients. But the success of the process and of PRO quality improvement efforts hinges on physicians' ability to disclose quality-of-care information in a nonpunitive environment, the Association said.

The American Health Quality Assn., which represents PROs, also said the complaint system needs reform but has concerns that PROs will be charged with assigning blame.

"PROs are focused on preventing quality problems from recurring, rather than figuring out who is responsible for what failings and punishing people," said AHQA Executive Vice President David Schulke. "PROs should ensure that complainants know their choices, so they may choose instead to rely on a licensing board or courts for punitive action." [...]