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COBRA Substandard
Care Act 1986
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| Government
addresses quality of healthcare
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A series of legislative actions
in the 1980s addressed quality issues in healthcare. Initially
in 1985 the Consolidated Omnibus Budget Reconciliation Act (COBRA)
gave the government authority to deny payment for services that it
considered "substandard." The Professional Review
Organizations (PROs) in every state were authorized to review care
and deny Medicare payment to healthcare providers (both to hospitals
and physicians) who did not meet the government quality
expectations. These reviews and subsequent denials became
known as "quality denials."
The initial legislation in 1985 mandated
that the PROs do both pre-admission reviews (to determine the
necessity of hospitalization) and also pre-procedure reviews of
specific surgical operations. Many in the healthcare field
felt this expansion of PRO responsibilities symbolized expansion of
"Big Brother" into the healthcare industry.
COBRA 1985 is P.L. 99-272.
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| Big Brother
Looks Beyond the Hospital Care Setting
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Additional major legislation
was passed in 1986. This is P.L. 99-509. The new law
expanded PRO review responsibilities for substandard care beyond the
inpatient hospital setting. Now the government, through the
PROs, began looking at quality of care issues in the following
settings:
- Ambulatory surgical centers (ASCs)
- Skilled nursing facilities (SNFs)
- Home health agencies (HHAs)
- Both inpatient and outpatient care from
Medicare risk-contract health maintenance organizations (HMOs)
With the passage of this legislation, the
peer review organizations are now required to report their findings
of substandard care to licensing and certification agencies. |
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| Today's focus
on quality
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During recent years, attention
of the government in monitoring quality of care issues is focusing
on outcome measurement. With powerful computer systems and
data mining techniques, government agencies are now regularly
looking at quality and outcome issues. They are monitoring
both clinicians and organizations providing healthcare services and
supplies. Some groups are looking at global safety issues
while others are addressing precise topics like medication
management. Since the government now pays almost half of the
US healthcare costs, should they be functioning in the role of "Big
Brother"? |
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