RESUMO
The implementation of the Medicare Prospective Payment System (PPS) has sparked growing concern that economic pressures on hospitals may adversely affect quality of care. Potential problems include: premature hospital discharge, inter-hospital transfers of severely ill patients, and increased performance of high-risk procedures on an outpatient basis. Quality assurance efforts by Peer Review Organizations (PROs) and by individual institutions should help keep these forces in check. It will be necessary, however, to develop better monitoring systems containing both clinical and financial "markers" to assure the medical appropriateness of inpatient, as well as ambulatory, services offered under PPS.
Assuntos
Grupos Diagnósticos Relacionados , Administração Hospitalar/tendências , Medicare , Sistema de Pagamento Prospectivo/tendências , Garantia da Qualidade dos Cuidados de Saúde/tendências , Mecanismo de Reembolso/tendências , Humanos , Organizações de Normalização Profissional/tendências , Estados UnidosRESUMO
The Health Care Financing Administration (HCFA) began implementation of the transition from the Third Peer Review Organization (PRO) Scope of Work to the Fourth PRO Scope of Work on October 1, 1991. PROs in 11 states are currently implementing newly-established medical review requirements under the "Scope of Work," the contract by which PROs are obligated to carry out their statutorily-mandated duties of determining the medical necessity, appropriateness and quality of care delivered to Medicare beneficiaries. Michigan's PRO (MPRO) is scheduled to implement requirements outlined in the Fourth Scope of Work beginning April 1, 1992. This article discusses the American Medical Association's (AMA) relationship to the PRO program and the transition from the Third to the Fourth Scope of Work including the status of the Uniform Clinical Data Set.