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4
Improving Quality and Performance
Measurement by the QIO Program
CHAPTER SUMMARY
This chapter examines approaches that can be used to help Qual-
ity Improvement Organizations (QIOs) and health care providers
fulfill the Centers for Medicare and Medicaid Services' vision of
providing "the right care for every person every time" through a
focus on quality improvement and performance measurement. The
committee recommends that the emphasis of the QIO program be
redirected to increase its immediate impact and to align its role
with expanding efforts at performance measurement and pay-for-
performance programs, as well as the eventual implementation of
a national performance measurement and reporting system.
As discussed in Chapter 2, the quality of health care for Medicare ben-
eficiaries has gradually been improving over time. Health care providers are
more likely to follow recommended guidelines for the treatment of many of
the most common conditions affecting the elderly, although significant gaps
in quality remain for many measures. To some extent, these improvements
may be the result of changes in accreditation, Conditions of Participation,
and professional recertification requirements, as well as efforts of Quality
Improvement Organizations (QIOs) to improve quality.
Safety remains problematic, however, despite the attention resulting
from an earlier Institute of Medicine (IOM) report (IOM, 2000; see also
Bleich, 2005; Leape and Berwick, 2005), and the need for improvements in
the quality of health care is still urgent and great (IOM, 2001; McGlynn
et al., 2003). We are now at a point in time when many important pieces of
the quality puzzle are coming together, creating a unique opportunity to
make rapid progress toward achieving the purpose of health care articu-
lated in 1998 by the President's Advisory Commission on Consumer Pro-
tection and Quality in the Health Care Industry (1998:1) and endorsed by
102
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IMPROVING QUALITY AND MEASUREMENT 103
this committee: "The purpose of the health care system must be to continu-
ously reduce the impact and burden of illness, injury, and disability, and to
improve the health and functioning of the people of the United States."
Key components of a major quality improvement strategy are now
emerging throughout the health care system:
· The federal government is taking the lead in developing a national
health information infrastructure and promulgating data standards.
· The Centers for Medicare and Medicaid Services (CMS) is creating
partnerships with other government, health professional, and consumer
stakeholder groups (such as the Centers for Disease Control and Preven-
tion, the Agency for Healthcare Research and Quality, the Nursing Home
Quality Initiative, the Institute for Healthcare Improvement, and the Ameri-
can College of Surgeons) to develop measures and new initiatives designed
to promote quality (CMS, 2005b).
· A coalition of stakeholders, working as the Ambulatory Care Qual-
ity Alliance, has proposed a set of quality measures that can be used to
monitor the ambulatory care provided by physicians. The Hospital Quality
Alliance has similarly convened groups and hospitals to report publicly on
performance measures. These alliances were formed independently by pri-
vate organizations to accelerate advances in quality.
· Fully 98 percent of prospective payment system hospitals now re-
port core measures voluntarily to Medicare.
· Public reporting of quality measures in CMS and the private sector
has increased and expanded (see Table A.3 in Appendix A).
· Voluntary reporting procedures by hospitals have evolved to form
a national system for the collection and analysis of data on safety mis-
takes under the Patient Safety and Quality Improvement Act of 2005
(P.L. 109-41).
· Medicare is implementing demonstrations of payment systems that
reward quality performance by health care providers.
· Congress is moving aggressively to consider new payment proposals
that encourage performance improvement.
· Many private payers are collecting data on quality measures, making
some of these data public, and paying providers on the basis of their scores
on these measures.
The convergence of these key components represents an opportunity to
enhance the quality of health care provided through the Medicare program
and nationwide. However, this convergence will not come about on its own.
As proposed in this committee's first report, Performance Measurement:
Accelerating Improvement (IOM, 2006), a national infrastructure--the
National Quality Coordination Board (NQCB)--is needed to help coordi-
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104 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
nate quality improvement activities in both the public and private sectors.
Such activities will involve quality improvement experts across the country
who can help collect, aggregate, and interpret data, as well as offer techni-
cal assistance to providers in implementing the internal system changes re-
quired to improve quality (IOM, 2006). The committee sees the QIO pro-
gram as ultimately operating synergistically with the NQCB. However, the
committee's recommendations for the QIO program are not tightly linked
to the NQCB because the former is an ongoing operational program, while
the latter has yet to be created, and its precise structure and direction can-
not be predicted.
Quality measurement and improvement are not easy and will take time;
the development of a coordinated infrastructure for quality improvement is
a first step. Providers will need help with developing the capacity to mea-
sure performance and incorporating quality improvement activities into
their practices. Small groups of physicians and solo practitioners, as well as
institutional providers lacking quality improvement staff and expertise, are
particularly likely to need assistance. QIO executives (in the committee's
interviews and site visits), providers, and purchasers say that they expect
the demand for technical assistance from providers to grow dramatically
(personal communication, F. deBrantes, General Electric, May 13, 2005).
The QIO program is the only public infrastructure devoted to quality
improvement with resources on the ground in every state, as well as with
electronic communications systems and expertise for transmitting, aggre-
gating, validating, and analyzing quality measurement data. Other organi-
zations have some capacity to offer technical assistance to promote perfor-
mance improvement efforts. For example, a number of private organizations
offer assistance through conferences, consulting, collaborative activities, and
web-based programs, primarily for hospitals and ambulatory care settings
(see Chapter 3 and Table B.1 in Appendix B). While some of these private
programs are free and available to certain types of providers, they generally
are not accessible to all providers across the country, particularly those who
cannot afford the costs or the time associated with registering for and trav-
eling to national meetings. The QIOs are able to provide local guidance for
providers in their own states without charging for the service--a unique
capability in that they can not only assist with quality improvement in gen-
eral, but also address local concerns regarding the implementation of gener-
ally accepted quality improvement techniques.
As discussed in Chapter 2, the evidence base regarding the effectiveness
of health care quality improvement interventions in general and the contri-
butions of the QIOs to improvements in the health care settings that serve
Medicare beneficiaries in particular is limited (see also Chapter 9). While
the committee recognizes that evaluations of an ongoing, operational pro-
gram are complex and that it is difficult to produce conclusive results, more
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IMPROVING QUALITY AND MEASUREMENT 105
evidence could have been generated by the program over its 35 years of
operation. Neither the U.S Department of Health and Human Services
(DHHS) nor CMS has made evaluation of the impact of the program and of
quality improvement interventions a priority for the QIO program. Greater
emphasis should be given to such assessments in the future. To conduct
appropriate evaluations that can be used to compare results, the QIO pro-
gram must have clear priorities and goals for such evaluations.
Uncertainty about the past impacts and future success of the QIO pro-
gram makes it difficult for the committee to decide on an appropriate future
role, if any, for the program. The lack of evidence for attributing improve-
ments to QIO efforts does not mean, however, that QIOs have had no
impact on the quality of health care. Moreover, it is clear that a large need
exists to help providers improve their quality of care and that the QIOs can
help meet this need. Therefore, the committee concludes that if the QIO
program were repositioned and strengthened to fulfill its potential, it could
support provider efforts to improve the quality of care received by Medi-
care beneficiaries and help support a national performance measurement
and reporting system. The committee believes the absence of QIOs would
be a significant loss for emerging quality improvement efforts, and that if
such a program did not exist, CMS would need to create one to fulfill its
obligation to ensure that all beneficiaries receive high-quality health care. In
addition, the committee believes the program's national support centers,
external support contracts for data and communications services, and funds
for research and development should all be focused on the new national
system for performance measurement and quality improvement (see Chap-
ter 3). Thus, the committee recommends that CMS redirect the emphasis of
the QIO program such that the technical assistance role of the QIOs is their
highest priority and the primary focus of all program resources. Moreover,
periodic evaluations should assess the program's impact on the quality of
health care services received by Medicare beneficiaries (see Recommenda-
tion 7 in Chapter 5 for a discussion of the recommended evaluations). The
remainder of this chapter details the committee's specific recommendations
for focusing the QIO program on quality improvement and performance
measurement.
TECHNICAL ASSISTANCE FUNCTIONS
Recommendation 1: The Quality Improvement Organization (QIO)
program must become an integral part of strategies for future per-
formance measurement and improvement in the health care sys-
tem. The U.S. Congress, the secretary of the U.S. Department of
Health and Human Services (DHHS), and the Centers for Medi-
care and Medicaid Services (CMS) should strengthen and reform
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106 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
key dimensions of the QIO program, emphasizing the provision of
technical assistance for performance measurement and quality im-
provement. These changes will enable the program to contribute to
improved quality of care for Medicare beneficiaries as they move
through multiple health care settings over time.
· Quality improvement should embrace all six aims for health care
established by the Institute of Medicine (IOM) (safety, effective-
ness, patient-centeredness, timeliness, efficiency, and equity).
· QIO services should be available to all providers, Medicare Ad-
vantage organizations, and prescription drug plans.
· QIO services should emphasize hands-on and other technical
assistance aimed at building provider capacity as needed by each
provider setting, such as:
Instruction in how to collect, aggregate, and interpret data on
the measures to be used for internal quality improvement,
public reporting, and payment.
Instruction in how to conduct root-cause analyses and deep
case studies of sentinel events or other problems.
Advice and guidance on how to bring about, sustain, and dif-
fuse internal system redesign and process changes, particu-
larly those related to the use of information technology for
quality improvement and those that promote care coordina-
tion and efficiency through an episode of care.
Enhancement of and technical support for the direct role of
providers in beneficiary education as an integral component
of improved care, better patient experiences, and patient
self-management.
Assistance with convening and brokering cooperation among
various stakeholders.
Technical assistance for quality improvement encompasses a multitude
of activities beyond interventions focused on the redesign of systems or the
use of new techniques (see Chapter 8). In the course of their quality im-
provement interventions over the past few years, for example, QIOs have
helped providers collect, aggregate, and interpret data from medical records
and other sources to determine the immediate changes resulting from those
interventions. Under the 7th scope of work (SOW), QIOs offered all hospi-
tals, home health care agencies, and nursing homes assistance with the col-
lection and interpretation of data, as well as with efforts to improve on the
measures reported to CMS for use on the websites made available to the
public for comparing the quality of care offered by different providers. QIOs
also helped hospitals with the reporting of the data. This experience in
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IMPROVING QUALITY AND MEASUREMENT 107
working with providers to collect data and with the media and the public to
interpret those data will be good preparation for offering the types of
assistance that will be needed as performance measurement and reporting
expand under a national system, and as providers become more strongly
motivated to reform their internal systems and processes to ensure better-
quality care. The committee anticipates that the rapid changes it envisions
in performance measurement and reporting and in payment for perfor-
mance, as well as the evolution of a national performance measurement
system, will increase interest in quality improvement interventions among
some providers who have not participated in such interventions to date and
who may need significant hands-on technical assistance.
The Conditions of Participation, the Joint Commission on Accredita-
tion of Healthcare Organizations, and the recertification requirements of
many specialty societies require competency activities that focus on quality
improvement and patient-centered care. According to a survey by the Com-
monwealth Fund, however, only 34 percent of physicians are actively in-
volved in systems redesign for quality improvement, and only 33 percent
receive data on the quality of the care they deliver (Audet et al., 2005). Yet
a study of physician practices and their use of common care management
processes (guidelines, registries, physician feedback, and case management)
for the chronic conditions of diabetes, asthma, congestive heart failure, and
depression showed that only 1 percent used the common management pro-
cess for each condition, although about half used the process for at least
one condition (Casalino et al., 2003). Clearly there is substantial room for
improvement. In telephone interviews, QIO executives suggested that the
provision of support for those providers who have been reluctant to adopt
quality improvements would likely be more labor-intensive than QIO ef-
forts to date and would present a challenge to the QIOs, but that these
providers may need help the most.
The adoption of electronic health records by providers is key to the
implementation of a national performance measurement system and the full
datasets recommended by the committee in the Performance Measurement
report (IOM, 2006). A few QIOs gained experience assisting physician prac-
tices with the adoption of health information technology and with the rede-
sign of their office systems during the 7th SOW under the Doctor's Office
QualityInformation Technology project. Most QIOs performed only a
small trial of this work at the end of the 7th SOW, however, and all QIOs
began this function in earnest only under the 8th SOW. The committee
anticipates that the QIOs in some states will have difficulty acquiring staff
with the necessary technical skills in computerized information systems,
and that it may be better for them to subcontract with a regional or central
entity that could provide this expertise. The QIO's own staff could then
focus on the system redesign and quality aspects of the implementation of
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108 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
information technology in the physician office setting, with physicians ob-
taining guidance from local professionals who can customize the QIO's
advice to the situation in their offices.
Other important QIO activities related to technical assistance for qual-
ity improvement include cooperation with local stakeholder organizations
for general educational information, promotion of coordinated care across
settings and time, and support for providers in their direct education of
individual beneficiaries, all of which can contribute to the larger goal of
more patient-centered care. While the committee recommends that the QIOs
focus on helping providers engage and educate beneficiaries, not on provid-
ing direct education to individual beneficiaries or patients, this recommen-
dation is in no way intended to diminish the importance of beneficiary
education as an aspect of patient-centered care. Indeed, the committee be-
lieves beneficiary education is an essential part of any physicianpatient
relationship, as well as any quality improvement approach, and should be
included as appropriate in all quality improvement interventions. QIO sup-
port for this function may include materials for direct education by the
provider, mailings or other such materials offered by the provider to pa-
tients, and coordination with efforts of consumer-focused community coa-
litions. QIOs should also help providers improve the patient-centeredness
of the care they offer by supporting beneficiaries in becoming more respon-
sible for their own care and by using consumer surveys to guide their prac-
tice patterns. The Center for Beneficiary Choices within CMS is responsible
for providing direct outreach and answering individual beneficiaries' ques-
tions on their rights under the Medicare program. QIOs should focus on
quality improvement and performance measurement activities aimed at im-
proving health outcomes and on related activities that contribute to patient-
centered care while the Center for Beneficiary Choices strengthens its direct
contacts with beneficiaries.
The scale of demand for technical assistance may surpass the capacities
of the QIOs if they do not develop tools and procedures that can be used to
assist greater numbers of providers more efficiently. Internet-based semi-
nars and other forms of web-based communications could expand the QIOs'
reach, and structured, self-administered toolkits might help providers
progress in some technical areas with fewer personal contacts from the QIO.
The QIOs will have to determine what types of assistance need to be per-
sonal and designed for a specific provider's situation and what assistance
can be delivered to groups of providers or applied by the provider inter-
nally. CMS should not delay exploring and testing alternative approaches
to technical assistance, such as train-the-trainer programs; electronic pro-
grams that can reach larger audiences effectively; and other improvement
tools used in the private sector, such as shared decision-making programs
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IMPROVING QUALITY AND MEASUREMENT 109
for particular preference-sensitive care choices. Collaboration and align-
ment of priorities will be essential to meet the demands of the future.
Another way QIOs can help achieve improvements more efficiently is
by convening providers to share best practices. The QIO Support Centers
are an important locus for efforts within the QIO program (see Chapter 5).
But it is important to note as well that providers associated with the QIO
program work with a patient population that goes beyond the Medicare
population and also includes patients from commercial health plans. Many
of these plans are also making efforts to improve quality and value for their
patients, creating another logical source for knowledge transfer. QIOs
should, as appropriate, coordinate with groups at both the local and na-
tional levels to determine the best approaches to improving quality.
QIO SUPPORT FOR QUALITY IMPROVEMENT EFFORTS
Recommendation 2: QIOs should actively encourage all provid-
ers to pursue quality improvement and should assist those pro-
viders requesting technical assistance; if demand exceeds
resources, priority should be given to those providers who dem-
onstrate the most need for improvement or who face significant
challenges in their efforts to improve quality. CMS should en-
courage and expect all providers to continuously improve the
quality of care for Medicare beneficiaries.
Considering the large gap that exists between the quality of health care
received by Medicare beneficiaries today and the level of care they should
be receiving, the committee strongly believes that all providers in every set-
ting should participate in formal efforts to improve the quality of the ser-
vices they deliver (IOM, 2001; Casalino et al., 2003; McGlynn et al., 2003).
Some providers, such as teaching hospitals and large group practices, have
the staff and expertise to devote to internal quality improvement efforts.
Many other providers do not have internal quality improvement programs
and may support staff participation in formal programs run by private firms
or the QIOs.
Currently, provider participation with QIOs is completely voluntary.
During the committee's site visits and interviews, most QIO chief executive
officers (CEOs) said they favored the voluntary nature of the program, rec-
ognizing that readiness for change and motivation are important aspects of
an effective quality improvement effort (see Chapter 8). They asserted that
working with opinion leaders and early adopters helps diffuse change. Al-
though the committee recognizes that readiness for change and motivation
are important factors in the quality improvement process, this does not
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110 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
change the committee's belief that all providers should be actively seeking
ways to improve the care they provide and need to take responsibility for
their actions.
Providers who volunteer for participation with QIOs may be at any
level of performance, including those already performing at a high level and
those with problems who are motivated to seek improvement. If a provider
is performing poorly but resists efforts to effect change, the QIO or other
quality improvement expert currently has little recourse. With the onset of
such initiatives as pay for performance and public reporting, however, many
more providers will likely seek help with improving the quality of the care
they deliver (personal communication, F. de Brantes, General Electric, May
13, 2005). CMS should establish priorities to guide the QIOs in selecting
providers to participate in technical assistance interventions should demand
exceed the resources available and too many providers request assistance.
Ideally, there should be sufficient funding to include early adopters and
opinion leaders along with more needy providers, and to cover the extra
QIO time and effort that may be required to assist some participants. As
part of its evaluation of the QIO program, CMS might seek to identify
those characteristics of providers that make them most receptive to and
successful in QIO quality improvement interventions. The evidence base
concerning early and late adopters of quality improvements is currently
quite limited and provides little guidance. Recommendation 8, presented in
Chapter 5, is aimed at allowing QIOs to charge providers or seek addi-
tional funds for quality improvement to expand their reach beyond the
Medicare core contract, thus enhancing the mix of providers receiving
assistance.
QIO BOARD AND ORGANIZATIONAL STRUCTURE
Recommendation 3: Congress and CMS should strengthen the or-
ganizational structure and governance of QIOs to reflect the new,
narrower focus on technical assistance for performance mea-
surement and quality improvement. Congress should eliminate
the requirement that QIO governing boards be physician-access
or physician-sponsored, while also enhancing the boards' ability
to provide oversight and direction.
· Congress and CMS should improve QIO governance by requir-
ing (1) broader representation of all stakeholders on QIO boards,
including more beneficiaries and consumers with the requisite
training and executive-level representatives of providers; (2) ex-
pansion of the areas of expertise represented on QIO boards
through the inclusion of individuals from various health profes-
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IMPROVING QUALITY AND MEASUREMENT 111
sional disciplines, group purchasers, and professionals in infor-
mation management; and (3) greater diversity of quality im-
provement professionals on QIO boards through the inclusion
of experts from outside the health care field and beyond the
local community.
· QIO boards should strengthen their committee structures
and consider development plans for individual members, imple-
mentation of annual performance evaluations, and annual as-
sessments of the board as a whole as well as plans for its
improvement.
· Organizations holding QIO contracts should include on their
websites a listing of members of their boards of directors, along
with information on the compensation provided to those mem-
bers and the chief executive officer.
Until the recent revelations about QIO board payments, the governance
of QIOs had not received much attention, but that situation is rapidly chang-
ing (Gaul, 2005). There is now a greater interest in board accountability
and transparency, an interest that extends to corporate governance gener-
ally in both the for-profit and not-for-profit sectors. Although the Sarbanes-
Oxley Act (P.L. 107-204) mandated changes in for-profit boards, several
organizations, such as Independent Sector, the Aspen Institute, and Board
Source, have focused on strengthening the governance of not-for-profit
organizations.
The current physician domination of most QIO boards results in un-
balanced representation that fails to include all the players needed to
achieve effective quality improvement interventions (see Chapter 7). For
the patient to become the focus of care delivery, greater participation of
beneficiaries at all levels of the quality improvement process is required. It
is unrealistic to expect a single beneficiary to shift the direction of a board
heavily dominated by providers (personal communication, D. G. Schulke,
October 18, 2005).
Most QIO boards would also benefit from broader representation of
individuals from the various health care professions, individuals at the ex-
ecutive levels of various provider organizations, and individuals from out-
side the health care field with expertise in information management and
oversight as well as quality improvement. In addition, a more formal, sys-
tematic, and clearly defined evaluation of the performance of individual
board members and overall board performance would likely stimulate stron-
ger board governance (Tyler and Biggs, 2005; McDonagh, 2005; Middleton,
2005; Orlikoff, 2005). In preparation for such board evaluations, it would
be helpful to provide ongoing training and development to enhance the
board's effectiveness as a team. Moreover, as transparency is an important
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112 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
aspect of performance measurement and quality improvement, information
on board members should be made transparent to the public and readily
available on each QIO's website.
From the beginning of the QIO program, contracting organizations
have been required to have formal physician-access or physician-sponsored
status (see Chapter 7). This requirement has contributed to the overall pre-
dominance of physicians on QIO boards. Local peer review has been based
on local standards of care, defined implicitly by local physicians, and is now
considered obsolete. This holdover legal requirement should be changed.
Removal of this requirement might also facilitate increased competition
from other entities when QIO contracts are opened for bids.
RESPONSIBILITY FOR COMPLAINTS, APPEALS,
AND CASE REVIEWS
Recommendation 4: Congress and CMS should develop mecha-
nisms other than those already in place to better manage complaints
and appeals of Medicare beneficiaries, as well as other case reviews.
The QIO in each state should no longer have responsibility for
handling beneficiary complaints, appeals, and other case reviews
for payment or other purposes.
· Reviews of beneficiary complaints regarding the quality of care
received are critical and should be a top priority for contractors
that treat the beneficiary as their primary client. CMS should
consolidate the review functions into a few regional or national
competitive contracts or determine the most appropriate agen-
cies with which to contract for the purpose in each state.
· To handle beneficiaries' appeals and other case reviews more
efficiently, CMS could contract at the national or regional level
with a limited number of appropriate organizations, such as fis-
cal intermediaries or individual QIOs. This devolution of re-
sponsibilities would allow QIOs to concentrate their resources
on quality improvement efforts with providers.
The QIOs will need to focus on quality improvement if they are to meet
the expected increase in demand for technical assistance among providers
discussed above. Earlier incarnations of the QIO program focused on case
review to identify and punish egregious outliers. In the 7th and 8th SOWs,
the balance shifted toward a greater emphasis on quality improvement ac-
tivities and less responsibility for complaints, appeals, and case reviews.
During the committee's site visits, it became clear that the QIOs are not
comfortable with the combined roles of technical assistant and regulator;
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IMPROVING QUALITY AND MEASUREMENT 113
the provider community holds a similar view (NORC, 2004; Bradley et al.,
2005). In the interest of attracting participants to their quality improve-
ment programs, the QIOs could favor collaborating with providers over
disciplining them, and could be less aggressive in their handling of com-
plaints. Moreover, the pressure on QIOs to maintain or improve their rela-
tionships with providers may grow under the 8th SOW, in which the weight
of hospital satisfaction ratings increases to 25 percent of the QIOs' evalua-
tion scores for the hospital quality improvement task (CMS, 2005c). In-
deed, the number of QIO recommendations for sanctions against physi-
cians and hospitals stemming from beneficiary complaints has dropped from
an annual average of 31 to an annual average of 1 over the last 20 years
(Gaul, 2005). During the 8-year period from 1986 to 1994, QIOs recom-
mended 278 sanctions against providers, whereas from 1995 to 2003 they
recommended only 12.
Beneficiary Complaints
The recommendation to shift the review of beneficiary complaints from
the QIOs to other entities does not imply any diminution of Medicare ben-
eficiary rights and protections. It is merely meant to transfer responsibility
for handling complaints from the QIOs to other agencies at the state, re-
gional, or national level. This shift should be effected for several reasons.
First, the committee is recommending that the quality improvement and
performance measurement functions become the focus of the QIOs, but
these technical assistance activities are incompatible with a strong regula-
tory function. Hence, the two functions should be separated. Second, the
number of complaints reviewed by QIOs nationwide is surprisingly small--
approximately 3,000 during fiscal year 2004, or about 1 for every 14,000
beneficiaries (Gaul, 2005; Rollow, 2005). Yet many beneficiaries may be
unaware of their local QIO and its complaint review function, even though
the contact information for all QIOs is listed in the Medicare handbook.
Another reason to support this shift of functions is that a plethora of
other organizations and agencies charged with investigating medical com-
plaints might handle the complaints of Medicare beneficiaries if given the
funds normally spent by the QIOs on complaint reviews. Some of the orga-
nizations may have greater visibility among consumers than others. Internet
searches for "[state] medical complaints" produce a variety of organiza-
tions, such as the state department of health or state department of insur-
ance, the nursing home ombudsman for the state, the state medical society,
and usually the QIO. Some QIO websites prominently feature information
on how consumers can submit complaints, but others do not. Internet
searches, moreover, do not necessarily make obvious which agency is most
appropriate for handling a particular consumer complaint.
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114 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
Beneficiary complaints should be reviewed under a contract that recog-
nizes the beneficiary as the primary client. CMS and the QIOs themselves,
as mentioned during the committee's site visits, currently recognize provid-
ers as the primary client of the QIO program (CMS, 2004). Again, working
collaboratively with providers and investigating their activities within a
single contract can create an inherent conflict of interest for the QIOs. Aside
from assigning the complaint task to an agency that considers beneficiaries
as the primary client, the ability of a contractor to perform these reviews
effectively needs to be considered. Data on QIO activities related to benefi-
ciary complaints are limited (see Chapter 12). Overall, QIO surveys of com-
plaints revealed high levels of beneficiary satisfaction with the complaint
review process but much lower levels of satisfaction with the outcomes of
the reviews.
A study by the Office of the Inspector General of DHHS in 2005 re-
vealed difficulties with CMS's beneficiary call centers (primarily 1-800-
MEDICARE) (DHHS, 2005). The study found that 84 percent of callers
were satisfied overall, but 44 percent had experienced problems with ac-
cessing information, while 24 percent had been unable to receive some or
all of the information they sought. The study also raised questions about
CMS's oversight of the accuracy of the information received. Two reports
of the Government Accountability Office in 2004 likewise showed prob-
lems with both 1-800-MEDICARE and Medicare carrier call centers (GAO,
2004a,b). A July 2004 study found that only 4 percent of 300 policy-
related calls made to carrier call centers had yielded correct and complete
answers. Similarly, a December 2004 study showed that only 61 percent of
420 callers to 1-800-MEDICARE had received accurate answers; the re-
maining answers either had been inaccurate or could not be provided. These
studies also suggested a need for improved oversight by CMS (see Chap-
ter 11 for further discussion). The above problems may not be unique to
CMS. Overall, however, the provision of confusing or incomplete informa-
tion and the lack of a central location where beneficiaries can lodge com-
plaints needs to be examined, with the aim of serving the best interests of
Medicare beneficiaries. In the interest of these beneficiaries, the complaint
process should be handled separately from the QIO core contract.
Under the 7th SOW, a new option of mediation was offered to benefi-
ciaries under very limited circumstances (see Chapter 12). As of July 2004,
only 15 states had completed at least one mediation under this new option
(Rollow, 2005). While this option is too new for its costs and value to be
assessed, the mediation procedure could be shifted to the agency that as-
sumes responsibility for conducting complaint reviews should Medicare
determine that the process is valuable.
The committee suggests that before determining where best to lodge the
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IMPROVING QUALITY AND MEASUREMENT 115
complaint review function, CMS examine the various national and regional
options for complaint review, as well as the agencies available for com-
plaint review in each state, the patterns of state responsibilities and delega-
tion of responsibilities for health care complaints or case reviews, and the
effectiveness of different agencies in handling complaints. Among the enti-
ties considered should be state health departments and the state Survey and
Certification agencies, which already contract with CMS to conduct certain
functions for the Medicare program, including the review of all quality-
related complaints for nursing homes.
Beneficiary Appeals
Recommendation 4 does not imply any reduction of the rights or pro-
tections of Medicare beneficiaries in appeals. In the past, both DHHS and
the Social Security Administration were involved in the appeals process
(GAO, 2005). Because of concerns about poor coordination, however, a
section of the Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000 (BIPA) (P.L. 106-554) calling for reforms to the
appeals process was enacted in December 2000. Additional reforms were
included in the Medicare Prescription Drug, Improvement, and Moderniza-
tion Act of 2003 (P.L. 108-173), including the transfer of all Medicare
appeals activities to DHHS by October 2005. (See Chapter 12 for more
information on BIPA appeals.)
Typically, when a service is denied or proposed for termination, the
beneficiary receives a written notice explaining the appeals process. During
fiscal year 2004, there were 8,168 expedited appeals and another 3,084
retrospective appeals. Private insurers review similar appeals, which are
handled through routine administrative procedures. The fiscal intermediar-
ies for Medicare might be the type of organization that could logically con-
duct such reviews because they are familiar with the benefit structure and
limitations on services. Because expedited reviews require the availability of
a full range of specialists who are on call 24 hours a day, 7 days a week and
decisions are now based primarily on national standards of care, it would
be more efficient to consolidate the review process for those cases at the
regional or national level instead of having each QIO support the full range
of on-call physicians for relatively few reviews. The review process is usu-
ally based on a review of records, which are faxed or delivered overnight;
they could as readily be sent to a regional office of the intermediary as to an
in-state QIO. Just as oversight of the appeals process has been consolidated
into one federal agency (DHHS), then, the appeals process itself may best
be carried out at the regional or national level (see Chapter 12 for detail on
the appeals process).
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116 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
Hospital Payment and Other Case Reviews
The QIOs have continued to conduct a substantial number of case re-
views concerning hospital payments and a smaller number of reviews in a
variety of different categories, although the overall volume of these reviews
has been much reduced over the years of the program (see Chapter 12). The
QIO program annually screened and abstracted a random sample of ap-
proximately 38,000 hospital claims during the 7th SOW, the mean pay-
ment error rate at the beginning of the 7th SOW was 4.33 percent (CMS,
2005a). Most payment errors in the hospital setting were found to be re-
lated to inappropriate admissions. Overall, CMS data show that over- and
undercoding mistakes tend to cancel each other out (Rollow, 2005).
QIOs conducted 46,000 other types of case reviews, mainly for hospi-
tal care, in fiscal year 2004 (Rollow, 2005). The value of each of these types
of reviews should be carefully assessed to see whether it exceeds the costs of
the review process. Such a study should consider the numbers of cases re-
viewed in each category, the net payment savings identified by the QIOs,
QIO and abstraction expenditures for each review, and other administra-
tive costs for processing the cases according to the QIOs' recommenda-
tions. The funds ultimately collected from providers and the deterrent effect
of the reviews, if any, should also be encompassed by such a study. On the
basis of the study results, the various case categories and the numbers of
cases could perhaps be pared down and better targeted before CMS deter-
mines whether case review services need to be continued under contract
separately from the QIO core contract. Reviews for cases with relatively
low volumes should be dropped. For example, from October 2002 to Sep-
tember 2004, QIOs performed only 14 reviews for the presence of an assis-
tant at cataract surgery, and all of those cases were approved (personal
communication, S. Blackstock, April 29, 2005).
If a few regional case review contracts were put up for competition,
Medicare's fiscal intermediaries, other private-sector entities, and possibly
organizations holding core QIO contracts might bid on those contracts. It
would be possible for an organization with particular skill in case review
holding a QIO core contract to win a contract that covered states where the
organization did not offer technical assistance for quality improvement.
Thus, a QIO could maintain its independence and focus on quality im-
provement with local providers without being perceived as threatening be-
cause of its regulatory activities.
In the committee's site visits and telephone interviews, QIO executives
mentioned two aspects of their case review functions that are of particular
value to them. First, some executives mentioned that through case review,
they have discovered quality problems common to more than one provider
and amenable to correction through a quality intervention. However, a new
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IMPROVING QUALITY AND MEASUREMENT 117
entity conducting case reviews could be charged with seeking such opportu-
nities and could perform similar analyses of its data for this purpose. Be-
cause the contractor would review cases from multiple states, it would be
able to identify a pattern unique to one state that the state-based QIO might
not recognize as aberrant. The use of national guidelines by out-of-state
reviewers should minimize any tendency to favor local practice patterns.
Detection of deviant patterns would also be enhanced with the implementa-
tion of a national performance measurement and reporting system. Addi-
tionally, QIOs would still be able to perform root-cause analyses in the
course of their technical assistance activities and in response to patterns
revealed through national case reviews or requests from providers perceiv-
ing internal problems. QIOs could still help providers with their corrective
action plans by performing these analyses and assisting providers with the
implementation of any changes necessary as a result of problems detected
by outside contractors.
A second indirect benefit of conducting case reviews cited by QIO ex-
ecutives is that the QIOs contract with a substantial number and propor-
tion of physicians in their states to conduct the reviews. As a result, a sig-
nificant number of local physicians are aware of the QIO and its activities,
and the QIO can communicate directly with these physicians about quality
issues. Some QIOs rely on their contracted physician reviewers to help pro-
mote their improvement interventions and serve as informal liaisons to the
rest of the provider community. The committee is cognizant of the value of
these relationships with providers for some QIOs. The committee suggests
that such informal relationships be maintained, but shifted to focus on us-
ing these providers to lead the implementation of performance measure-
ment activities in outpatient office practices and to encourage the adoption
of health information systems.
The committee recommends that the QIOs focus solely on quality im-
provement and support for performance measurement for three reasons:
· QIOs experience inherent conflicts in carrying out regulatory respon-
sibilities while partnering in quality improvement activities with the same
providers.
· The budget for the 8th SOW provides too little funding for the QIOs
to accomplish the full range of mandated technical assistance activities while
achieving transformational change.
· Most important, technical assistance for activities related to quality
improvement is the highest priority, and the infrastructure of the QIO pro-
gram is best positioned to provide that assistance. Other organizations could
assume the responsibility for complaints, appeals, and case reviews.
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118 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM
With the QIOs focusing all of their energies on quality improvement
and performance measurement activities, it may be hoped that progress on
quality improvement measures will be more substantial for all providers.
Whether QIOs will be able to meet the challenges of the future, however,
will depend in part on how CMS manages the program. Adequate evalua-
tions of the accomplishments of the QIO program as a whole and of indi-
vidual interventions will also depend on CMS management. The results of
those evaluations should influence future program directions and funding,
if any. These issues are addressed in the next chapter.
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Representative terms from entire chapter:
qio program
