U.S. Proposes to Link Quality of Care to Medicare Payments

The federal Medicare program proposed new regulations Friday that would deny payment to hospitals and physicians that deliver substandard hospital inpatient care.

The new regulations would increase the government’s ability “to ensure that Medicare beneficiaries receive high-quality care,” said Dr. William L. Roper, administrator of the Health Care Financing Administration.

Under the regulations, peer review organizations, the watchdog groups in each state that oversee health care for the elderly and disabled under contract to the federal government, would be authorized to deny Medicare payments when substandard care harms a patient or unnecessarily places the patient at high risk.

Roper said poor quality care might include unnecessarily prolonged treatments and complications that require readmission to the hospital or that lead to disability or death.

The draft regulations require that patients be notified when payment is denied for poor quality care; they also prohibit physicians and hospitals from charging patients in such instances.

When the review groups find that care is substandard but does not result in harm to the patient, Medicare would pay for the claim but the review group would be expected to conduct a follow-up review and work with the physicians and hospitals responsible to correct the problem.

The new regulations were required by Congress. The health care agency said it would issue final regulations after a 60-day comment period.