The United States is on the verge of major health care reform based on the managed competition model. As a necessary complement to health reform legislation, this policy report proposes a comprehensive national program to evaluate and monitor the quality of care provided to all Americans regardless of payer, provider, consumer, or site of care. The program must rely on federal mandates for the reporting of health care information and nationally driven policies on clinical consensus, but should be implemented through a statewide infrastructure of Health Quality Foundations interacting with other appropriate regulatory mechanisms. The goals of the program will be to: empower consumers with health care information that can help guide their decision making at all levels in the system; protect consumers from compromises to quality that a managed competition system invites; and facilitate provider quality improvement initiatives through an active program of quality monitoring accompanied by education and feedback.

1

Institute of Medicine, The Journal of the American Medical Association, October 27, 1993, p. 1911

2

Institute of Medicine, Assessing Health Care Reform, National Academy Press, Washington, DC. 1993, p. 35-36

The American Medical Peer Review Association (AMPRA) is a national membership association dedicated to improving the quality of health care delivery in the United States for all consumers through the creative application of quality evaluation programs and services.

AMPRA's current membership includes the federally designated Peer Review Organizations (PROs) under contract with the Medicare program. AMPRA works with its members and other interested parties to promote quality evaluation programs at the local level.

To link AMPRA's practicing review community with the work of health services researchers, AMPRA is affiliated with the American Medical Review Research Center (AMRRC), a non-profit, 501 (c)(3) public benefit, research and education organization dedicated to advancing the art science of quality assurance and quality medical peer review. AMRRC is a national information, evaluation, testing, and analysis resource for practical tools, methodologies, and programs in quality evaluation. AMRRC is presently working under contract with the Agency for Health Care Policy and Research to develop practice guideline-based review criteria and performance measures.

For further discussion or additional copies please contact:

Andrew Webber

Executive Vice President

American Medical Peer Review Association

810 First Street, NE, Suite 410

Washington, DC 20002

(202)371-5610 or Fax (202)371-8954

Mr. CARDIN. It is always nice to welcome a friend to the President. Dr. Kerschner.

STATEMENT OF PAUL KERSCHNER, PH.D., CHAIR, COALITION FOR CONSUMER PROTECTION AND QUALITY IN HEALTH CARE REFORM

Mr. KERSCHNER. Thank you, Mr. Cardin. Until 1 month ago, I was one of your very satisfied constituents.

Mr. CARDIN. Did you move or are you just not satisfied now? Mr. KERSCHNER. I got tired of 15 years of commuting and moved into the District to flee the crime in Maryland.

I am the executive director of the Gerontological Society of America and chair of the Coalition for Consumer Protection and Quality in Health Care Reform. The Coalition applauds the President's allout effort to reform the Nation's health care system. Our job now is to recommend specific improvements where necessary.

Mr. Chairman, the Coalition's members know what it is like for health care consumers under the current system. They are vulnerable to losing benefits or being denied coverage. The managed care model relies on competition between health care plans and providers to drive down the cost of care and drive up the quality of care. But there are obvious incentives for plans to contain costs while providing less service, so we believe a systematic approach to protecting consumers must be implemented. Allow me to summarize our recommendations.

Under quality improvement and public accountability, the Health Security Act provides an excellent foundation for independent monitoring of quality. However, the Coalition strongly believes there is a missing component. The bill does not satisfy our basic principle that there must be an external quality review entity independent of the payer-based alliance and provider-based plan, systems to monitor and improve quality in each State.

The Coalition also believes that what we call "quality improvement foundations" should be created in each State by the National Quality Management Council through competitive grants. The QIFS would be governed by a consumer majority board which would also include experts in a variety of health and quality research fields. Each QIF would perform quality monitoring and improve functions such as development of and support for quality improvement activities, practice guidelines, adherence monitoring and profiles of the database for low rates of utilization. This would ensure that quality improvement activities, which are currently very successful in some hospitals and with some health care professionals, will be used consistently across the Nation.

The QIF also will ensure that information regarding consistently poor care and poor plans will be forwarded to the appropriate entities. Under consumer representation, public accountability depends greatly on consumer representation on advisory boards, including the advisory boards for regional and corporate alliances, the National Quality Management Council and the State-located quality improvement foundations. In fact, Coalition members would argue that consumers must have a majority on these advisory boards since they are both the recipients of care and the ultimate source of financing.

Licensing and certification: Rigorous professional licensing and accreditation and planned certification is needed to ensure quality of care. Licensing boards and other regulatory bodies must sanction those that fail to provide acceptable care. We believe that the subcommittee should address ways to mandate sufficient financial support port for licensing boards and mandated at the national level, at least minimum functions to assure consistency from State to State. Ombudsman: We are pleased that the Health Security Act calls for the creation of ombudsman offices to serve as consumer advocates and help negotiate the system, resolve complaints and problems with the quality of services and facilities. However, we request that you provide greater detail about this program and how it can be used by consumers.

For example, the ombudsman program must have a stable source of financing not only one of voluntary contribution. We strongly believe that corporate enrollees should have the same access to an ombudsman as regional alliance enrollees; they currently don't. Also, ombudsman offices must be independent of plans and alliances to protect from conflicts of interest. Under any new system, consumers will need easy access to unbiased information to help them make meaningful choices between plans, providers and coverage options.

I should mention that consumers will benefit greatly by the inclusion of point-of-service options. A managed care system's competitive success depends greatly on the quality of information provided to consumers. Therefore, we request that you define more precisely the kinds of information that will be available to consum

ers.

For example, the Consumer Handbook should include the results of the consumer satisfaction survey conducted by the National Quality Management Council, enrollment and disenrollment figures collected by the Health Care Information System. Consumers will also need information such as physician certification and repeated disciplinary actions, and they will need condition-specific information to be able to choose between doctors and hospitals when they face major surgery.

The Coalition believes that due process rights are essential in any national health care plan and is quite pleased with the appeals process provided in the Health Security Act. We would, however, like to offer several refinements. Most importantly, we believe that Congress must clarify the circumstances for providing notices to patients when decisions to deny, reduce or terminate a service or payment have occurred in order to protect patients who may not know their benefits or options. These are all from low-income or less-educated consumers.

Notices should, one, state the specific reasons for the decision and describe the appeals process; and two, be triggered automatically whether certain benefits have been denied reduced or terminated.

It also appears that the burden falls too heavily on the consumer to provide a necessity for treatment and places the responsibility and cost of purchasing second opinions on the beneficiary.

Mr. Chairman, the Coalition is grateful to you for holding this hearing, and we look forward to working with you and your colleagues.

Mr. CARDIN. Thank you.

[The prepared statement and attachments follow:]