Statistical sampling in a legislative framework for peer review of medicare services

This article discusses problems addressed in developing an efficient way of identifying levels of inappropriate professional practice in delivery of Medicare services, using statistical sampling within a legislative peer-review scheme. An efficient alternative to the current sampling methodology is proposed.     

Protecting Medicare: the best defense is a good offense

Traditional Medicare is being threatened from two political directions. The current Republican coalition, on the right, simply dislikes social insurance in principle. It seeks privatization for its own sake. Another perspective, centrist and well established among political and economic elites, worries that the program is "unaffordable," whatever its basic merits. Defenders of traditional Medicare need to address both threats by explaining why the budgetary fears are misconceived and why privatization is simply a bad idea. In order to do this, they need to take the budgetary high ground, argue more strenuously for short-term cost controls, and criticize the extra spending that the Bush administration has used to encourage private plans within Medicare. Defenders of social insurance should also seek good policy and political allies by proposing that Medicare's network of providers, prices, and administration be made available to employers (and other pools) in much the way that self-insured groups currently rent networks from private insurers.     

Medicare program; payment to hospitals for furnishing photocopies to peer review organizations--HCFA. Final rule

This final rule amends the regulations governing Utilization and Quality Control Peer Review Organizations (PROs) to provide for a uniform methodology for determining payment to hospitals for the costs of furnishing photocopies of medical records of Medicare beneficiaries to PROs. We also are establishing the rate of payment for these costs at $.07 per page. This amount includes payment for labor and supply costs, but not the costs of equipment and overhead, which are already otherwise paid under the Medicare program.     

The co-regulation of medical discipline: challenging medical peer review

The medical profession has always fiercely defended its right to self-regulation on the basis of peer review. However, in New South Wales, Australia, the profession has willingly surrendered these rights in favour of a disciplinary system known as co-regulation or collaborative regulation, under which disciplinary processes are shared with a "lay" body, the Health Care Complaints Commission. The system constitutes a unique situation in the history of medical regulation. This article examines the origin and operations of co-regulation and comes to the conclusion that its successful operation over the last decade raises questions about whether peer review is indispensable as the basis of medical regulation.     

Evaluation of technology transfer by peer review

We report the outcome of an experiment in the field of program evaluation. Because of the rapid outward growth of technology transfer from federally funded laboratories, it was judged necessary to devise a new, yet effective, way of evaluating technology transfer programs and comparing them to conventional research and development projects. Specifically, technology transfer projects within the High-Temperature Superconductivity program of the Department of Energy were subjected to peer review evaluation by a panel of researchers who themselves conduct technology transfer activities. The evaluation criteria and procedures resembled those used for peer review of basic research, but were adapted to the characteristics of technology transfer projects. We include both the viewpoints of a laboratory being evaluated and of the panel chairman. We comment on the degree of success of this evaluation, and draw some conclusions about how it might be modified for the future.     

Medicare program; application of inherent reasonableness payment policy to Medicare Part B services (other than physician services). Final rule

This final rule finalizes the process that was set forth in an interim final rule published on December 13, 2002, for establishing a realistic and equitable payment amount for Medicare Part B services (other than physicians' services) when the existing payment amounts are inherently unreasonable because they are either grossly excessive or grossly deficient. This process does not apply to services paid under a prospective payment system, such as outpatient hospital services or home health services. The December 2002 interim final rule also described the factors we (or our carriers) will consider and the procedures we will follow in establishing realistic and equitable payment amounts for Medicare Part B services. In addition, this final rule responds to public comments we received on two provisions in the December 13, 2002 interim final rule relating to how we define grossly excessive or deficient payment amounts and to the criteria for using valid and reliable data in applying the inherent reasonableness authority.     

Medicare program: suppliers of specialized services; technical amendment--HCFA. Technical amendment

A final rule with comment period, pertaining to providers and suppliers of specialized services, published on September 29, 1995 at 60 FR 50446, redesignated 42 CFR part 485, subpart D as 42 CFR part 486, subpart G, and corrected internal cross-references as required by the redesignation. This document corrects one cross-reference that we failed to identify in the final rule with comment period.     

Federal antitrust jurisdiction in peer review cases: the Pinhas decision

In Summit Health Ltd. v. Pinhas, the United States Supreme Court by a narrow majority found that the exclusion of an ophthalmologist from a hospital in Los Angeles had a sufficient effect on interstate commerce to establish federal jurisdiction under the Sherman Act. In resolving a split among the federal circuit courts of appeal, the Court applied the broad jurisdictional test from McLain v. Real Estate Board of New Orleans, Inc. to peer review proceedings. Despite many ambiguities in the majority opinion by Justice Stevens and a scathing dissent by Justice Scalia, the effect of Pinhas will be to increase the suits in federal court on antitrust grounds brought by aggrieved medical staff members and applicants denied appointments or privileges, and to decrease, if not eliminate, the likelihood of preliminary dismissal on jurisdictional grounds. This, in turn, should serve to emphasize the importance of complying with the Health Care Quality Improvement Act in order to obtain immunity from damages under federal antitrust and state laws.     

Medicare program; Medicare coverage of home health services, Medicare conditions of participation, and home health aide supervision--HCFA. Final rule

This regulation specifies home health aide supervision and duty requirements applicable to all home health agencies (HHAs) and hospices that furnish home health aide services under the Medicare program. It also specifies limitations and exclusions applicable to home health services covered under Medicare. The purpose of this regulation is to clarify Medicare home health policy and to promote consistent administration of the home health benefit.     

Medicare and Medicaid programs; hospital conditions of participation: laboratory services. Final rule

This final rule finalizes the hospital conditions of participation requirements for hospitals that transfuse blood and blood components. It requires hospitals to: Prepare and follow written procedures for appropriate action when it is determined that blood and blood components the hospitals received and transfused are at increased risk for transmitting hepatitis C virus (HCV); quarantine prior collections from a donor who is at increased risk for transmitting HCV infection; notify transfusion recipients, as appropriate, of the need for HCV testing and counseling; and extend the records retention period for transfusion-related data to 10 years. The intent is to aid in the prevention of HCV infection and to create opportunities for disease prevention that, in most cases, can occur many years after recipient exposure to a donor.     

Medicare program; application of inherent reasonableness to all Medicare Part B services (other than physician services)--HCFA. Interim final rule with comment period

This interim final rule implements section 4316 of the Balanced Budget Act of 1997. It revises the process for establishing a realistic and equitable payment amount for all Medicare Part B services (other than physician services) when the existing payment amounts are inherently unreasonable because they are either grossly excessive or deficient. This rule describes the factors HCFA (or its carrier) will consider and the procedures it will follow in establishing realistic and equitable payment amounts.