Peer review organizations. Promises and potential pitfalls.

Area of Science:

• Health Services Research
• Quality Improvement
• Healthcare Policy

Background:

• The Health Care Financing Administration contracted 54 Peer Review Organizations (PROs) to oversee Medicare patient hospital care.
• PROs committed to reducing readmissions, unnecessary procedures, and avoidable mortality/morbidity.

Purpose of the Study:

• To analyze the variability in reduction targets set by PROs.
• To identify potential challenges PROs may face in achieving their quality improvement goals.

Main Methods:

• Review of contract summaries for 49 PROs.
• Analysis of stated reduction targets and potential implementation barriers.

Main Results:

• Significant variation exists in the reduction targets established by different PROs.
• Potential pitfalls include data inaccuracies, inadequate patient/physician descriptors, and differing clinical judgments.
• PROs may be perceived more as cost-containment agents than quality assurance bodies.

Conclusions:

• PROs face challenges in meeting quality objectives due to target variability and operational hurdles.
• Establishing an expert panel of clinicians and researchers could enhance PRO credibility and effectiveness in setting and achieving quality care objectives.