Accreditors Blamed for Overlooking Problems

Nelson J. Sabatini, Maryland's health commissioner during the troubles at Maryland General, said federal oversight of health care is "a fraud. A lot of what they call regulation is really self-regulation," he said. "They're being told to be partners. It doesn't work."

Under Medicare rules, any hospital meeting the joint commission's standards automatically is eligible to participate in the federal health program and receive government reimbursements. Over the years, to save money and avoid duplicating federal efforts, all but a handful of states have abandoned their separate procedures for licensing hospitals and now rely on the joint commission.

The group's role, O'Leary said, is to help hospitals and other facilities meet the standards, not to regulate or punish them.

"We can't fine you or close you," O'Leary said. "It's right in the articles of incorporation. Our role is to evaluate and educate."

The joint commission is one of three main legs in Medicare's oversight system. To ensure that the care it pays for meets quality standards, Medicare also allocates more than $250 million a year to state regulators to investigate complaints and inspect a wide range of health care facilities. And it awards nearly $300 million annually to private groups in each state called Quality Improvement Organizations, which work closely with hospitals and others to improve care and review patient concerns.

In recent years, Medicare officials have stressed a more collegial approach in which the private groups and even some state regulators work together with the hospitals and other groups they oversee. The focus of this approach is collaboration, not punishment.

The joint commission is a good example of the change. The idea is that collaboration and continual monitoring can result in broader improvements and better care than simply weeding out poor performers.

But some critics say the outsourcing and shifting focus of Medicare's oversight system puts patients at risk.

The relationship between Medicare and the joint commission is a large part of the problem, Sabatini said. "The fundamental structure of the joint commission doesn't make sense," he said. "It's one big built-in conflict, and the fact that Medicare allows it is appalling."

For their part, Medicare officials say they are required by law to accept the joint commission's congressionally mandated accreditation system.

"Legally we have no authority" over the commission, said Frank Sokolik, who directs hospital surveys for the Centers for Medicare and Medicaid Services, the agency that oversees the giant federal insurance program.

"We work together," Sokolik said, "but there is no requirement they do anything."