Can We Be Certain of PRO Accuracy and Accountability? Inaccurate "Report Cards" Generated by Medicare Claims Data as a Marker for Laboratory Testing in Diabetic Patients

Abstract

Quality of care attributed to individual physicians will be made public more frequently in the future. Inaccurate reports could damage physicians both professionally and financially. Using claims data for services rendered to Medicare patients from 1997 through 2000, The New Jersey Peer Review Organization (PRO) reported the percentage of each physician's patients who received testing for HgB Alc and for lipid profiles. We reviewed the patient records kept by these physicians to calculate the actual percentage of patients who received these tests. A statistically significant difference existed between the PRO's data and our results. Use of claims data as a marker for services provided can lead to inaccurate inferences about the quality of care provided by individual physicians, which can have potentially negative consequences to these providers.

Keywords

Billing database diabetes Medicare peer review organization quality report cards

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