Medicare Beneficiary Complaint Program in the News January 10, 2001 Last week, articles were published in The New York Times and USA Today regarding possible new regulations governing the Medicare Beneficiary Complaint Program. This program is administered by HCFA through contracts with the nationÕs network of Peer Review Organizations (PROs). At issue is whether Medicare is going to require the PROs to publicly disclose the identities of individual practitioners when a PRO's investigation of a beneficiary complaint identifies a problem with the quality of care provided. Current Medicare rules sharply limit what the PROs may tell a complainant about the "final disposition" of the investigation of their complaint. In addition, PROs are prohibited from revealing the identities of specific health care practitioners involved in the case. A New Balance Should Be Found. The American Health Quality Association (AHQA) accepts that beneficiaries should get more information about the findings of a complaint investigation and we support reforming the current rules as necessary to make this happen. We do not, however, support releasing the identities of individual practitioners. Individual need must not harm Medicare's commitment to improving quality for the more than 40 million Medicare beneficiaries. Clinical Quality Improvement Efforts Cannot Be Sacrificed. Research has repeatedly found that most quality problems are caused by the failure of one or more systems and are best resolved by a consistent, organized and ongoing program to bring about system change - not by singling out one individual in a care giving system for punishment. The PROs are currently working on national clinical quality improvement (QI) projects with nearly every Medicare participating hospital in the country. PRO investigations stemming from complaints also form the basis for additional local QI projects. Efforts to force the PROs to "name names" will drive a wedge between physicians and PROs who are working collaboratively on these QI initiatives. Drawing the Line Between Consumer Information and Malpractice Suits. There is no clear agreement in the ongoing debate between the practitioner and consumer communities as to how much information regarding a particular complaint investigation can be released to the beneficiary without undermining QI efforts. Furthermore, physicians want assurance that the nation's network of QI organizations are not going to be converted into a publicly funded fact-finding service for trial attorneys. Confidentiality Concerns are Similar in Medical Errors/Patient Safety Debate. The 1999 IOM report, To Err is Human, highlighted the importance of having strong protections for practitioners in order to create an environment in which errors might be identified and systemic changes could be made without fear of legal liability. AHQA worked to assure that every major medical error reduction bill in the 106th Congress placed a priority on giving practitioners confidentiality protection if they participate in QI efforts. The same consideration and balance must be applied to changes in Medicare's system for handling beneficiary complaints. AHQA would like to assist congressional staff in finding sensible middle ground on this issue. We welcome the opportunity to further discuss this issue with you. Please contact Sylvia Gaudette or Greg Johnson in the Government Affairs Department of AHQA for more information.