Medicare Patients Entitled To Receive Investigation Results

JUNE 30, 2003 VOLUME 10, NUMBER 52

Like other patients, Medicare beneficiaries sometimes receive poor medical care. When a Medicare patient complains about the quality of his or her care, federal law mandates a formal review process. It also requires that the patient be informed of the results of that review. Until a recent federal court decision, the government took the position that simply telling the patient the matter was being “looked into” was enough.

Doris Shipp was a patient at Baptist East Hospital in Louisville, Kentucky, from December, 1998, until her death from cancer in June, 1999. After her death her husband David Shipp wrote to the Peer Review Organization (PRO) responsible for oversight of Baptist and the three physicians treating Mrs. Shipp, asking for a review of the quality of care she had received.

Because two of the physicians refused permission to disclose the results of the PRO review of care, Mr. Shipp received a letter informing him only that the PRO had “carefully examined all the issues raised in your correspondence and conducted a thorough review of the care your wife received.” The notice also, unhelpfully, informed Mr. Shipp that the PRO “will take all necessary action when our review findings warrant it.”

Mr. Shipp sought help from Public Citizen, Inc., a nonprofit consumer advocacy group. Public Citizen filed a federal court lawsuit seeking more information for Mr. Shipp and other patients (or survivors) who have concerns about the quality of Medicare services. The Federal District Court agreed with Public Citizen and ordered the government to change its rules to require PROs to actually provide information to patients about the results of their investigations.

The U.S. Court of Appeals for the District of Columbia Circuit agreed with the trial court, and upheld the order invalidating federal rules. At a minimum, ruled the appellate court, the PRO must “disclose its determination as to whether the quality of the services that the recipient received met ‘professionally recognized standards of health care.’” The case was returned to the District Court for further proceedings—partly to determine whether the new government rules must also provide for disclosure of any corrective action by the PRO. Public Citizen, Inc., v. U.S. Dep’t of Health and Human Services, June 20, 2003.

Since Mrs. Shipp’s death the government has changed the name of PROs to “Quality Improvement Organizations.” As a result of the case pursued in Mrs. Shipp’s name, quality of care should now be somewhat easier for Medicare patients to monitor. Thanks go in part to Mr. Shipp’s persistence, partly to Public Citizen, Inc., and partly to The Center for Medicare Advocacy and AARP, which filed a brief supporting Public Citizen’s position.

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