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11 Beneficiary Education and Communications CHAPTER SUMMARY This chapter describes the activities of the Quality Improvement Organizations (QIOs) under Task 2 of the 7th scope of work (SOW), Improving Beneficiary Safety and Health Through Infor- mation and Communications. Under this task, the Centers for Medicare and Medicaid Services (CMS) charged the QIOs to in- form beneficiaries about the purpose of the QIO program, their rights under the program, and how to exercise those rights (CMS, 2002, 2004b). The QIOs worked with other stakeholders in their geographic regions to coordinate beneficiary-related activities. Spe- cific communications activities included the promotion of public reports of quality. The QIOs also assisted hospitals with prepara- tion for self-reporting on the quality-of-care measures for these re- porting efforts. Additionally, the QIOs maintained toll-free help lines; ensured consumer representation in their own organizations; and produced annual reports on their case review activities, which were available to the public. In the contract for the 8th SOW, CMS defined beneficiary education and communications activities only on a limited basis. TASK 2A: PROMOTING THE USE OF PERFORMANCE DATA Background During the 7th SOW, the Quality Improvement Organizations (QIOs) assisted the Centers for Medicare and Medicaid Services's (CMS's) efforts to measure quality and disseminate quality information on Medicare pro- viders in the nursing home, home health agency, and hospital settings through public reporting (CMS, 2002). CMS launched the Nursing Home 279

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280 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM Quality Initiative in November 2002. That initiative sought to help benefi- ciaries, their families, hospital discharge planners, and others make deci- sions regarding long-term care as well as to encourage and help nursing homes improve the quality of care that they provide. The initiative worked in conjunction with Medicare's release of Nursing Home Com- pare (www.medicare.gov/NHCompare/home.asp), a website that allows consumers to compare nursing homes on the basis of certain quality mea- sures and other information, such as staffing levels and type of ownership. In 2003, CMS began the Home Health Quality Initiative, which involved the public reporting of quality measures for home health agencies on the Home Health Compare website (http://www.medicare.gov/HHCompare/ home.asp.) In March 2005, CMS launched the Hospital Compare website (http://www.hospitalcompare.hhs.gov.) CMS charged the QIOs to help promote each of these reporting efforts. The QIOs encouraged consumers to visit the sites, answered their questions, offered providers technical as- sistance with improving their performance on the reported quality mea- sures, and promoted the sites to local media. The specific required activi- ties included: Development of a work plan to promote each initiative, including state and local activities; Participation in CMS communications conferences; Distribution of appropriate materials; Coordination of media outreach; Response to consumer needs; and Attendance at CMS training sessions (CMS, 2002). Task 2a Data Figure 11.1 shows the numbers of webpage views for the Nursing Home Compare, Home Health Compare, and the Hospital Compare websites. The Dashboard section of the CMS internal website (see Chapter 13) de- fines a webpage view as "the number of times an entire Web page was viewed, regardless of the number of graphics, objects, or embedded ob- jects" (QIONet Dashboard, accessed November 11, 2005). The number of webpage views per month appeared to be steady over the year-long period reflected in Figure 11.1; however, changes in the number of webpage views cannot necessarily be attributed to the activities of the QIOs. Additionally, these exposures are likely attributable to consumers as well as health care providers themselves. Table 11.1 presents the numbers of telephone calls to 1-800- MEDICARE for nursing homerelated issues. (1-800-MEDICARE is the national telephone number provided to beneficiaries and others to answer

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BENEFICIARY EDUCATION AND COMMUNICATIONS 281 1,600,000 1,400,000 1,200,000 1,000,000 NH Compare 800,000 HH Compare 600,000 Hospital Compare 400,000 200,000 0 Apr-04 Jun-04Aug-04Oct-04Dec-04 Feb-05Apr-05 FIGURE 11.1 Numbers of webpage views (as of June 10, 2005). NH Compare = Nursing Home Compare website; HH Compare = Home Health Compare website. SOURCE: QIONet Dashboard (accessed November 11, 2005). TABLE 11.1 Nursing HomeRelated Calls to 1-800-MEDICARE Number of Number of Date Number of Total Number Referrals Print-on-Demand (mo-yr) Unique Calls of Topics to a QIO Requests Jan-04 3,126 4,029 NAa 100 Feb-04 2,662 3,277 69 88 Mar-04 3,156 3,811 65 72 Apr-04 2,749 3,303 82 72 May-04 1,310 1,599 29 51 Jun-04 2,373 2,898 49 67 Jul-04 2,632 3,167 45 78 Aug-04 4,998 6,027 72 111 Sep-04 3,701 4,328 63 70 Oct-04 4,044 4,672 47 45 Nov-04 4,803 5,566 84 71 Dec-04 4,919 5,741 93 78 Jan-05 6,636 7,775 121 104 Feb-05 7,115 8,290 138 80 Mar-05 7,550 8,688 118 88 Apr-05 7,013 8,069 128 78 May-05 6,747 7,805 110 57 NOTE: Data are as of June 10, 2005. aNA = not available. SOURCE: QIONet Dashboard (accessed November 11, 2005).

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282 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM any Medicare-related question. It is not one of the help lines run by indi- vidual QIOs. Other issues related to 1-800-MEDICARE are discussed later in this chapter.) The data show the number of individual callers as well as the number of nursing home topics discussed. Note that each caller may discuss more than one topic. Table 11.1 also shows the numbers of callers to 1-800-MEDICARE who were referred to QIOs. Finally, the last column presents the total number of Nursing Home Compare print-on-demand requests. CMS generates these documents when a caller requests printed information from Nursing Home Compare. The data show an approxi- mate doubling of the numbers of unique calls, the numbers of topics dis- cussed, and the numbers of referrals made to QIOs over the entire time period. The numbers of referrals made from 1-800-MEDICARE to individual QIOs as a result of these nursing homerelated calls are shown in Fig- ure 11.2. Table 11.2 presents the numbers of calls to 1-800-MEDICARE related to home health topics. The table breaks down the topic areas mentioned in all calls. Again, one caller may mention multiple topics. Interestingly, except for a sudden drop in the last 2 months of report- ing, the data show gradual increases in both the total numbers of com- plaints and the total numbers of home health carerelated topics discussed during this time period (see Figure 11.3). 160 140 120 100 80 60 40 20 - Feb-04 Mar-04Apr-04May-04 Jun-04Jul-04Aug-04Sep-04Oct-04Nov-04Dec-04 Jan-05 Feb-05 Mar-05 Apr-05May-05 FIGURE 11.2 Referrals to QIOs from 1-800-MEDICARE for nursing home topics (as of June 10, 2005). SOURCE: QIONet Dashboard (accessed November 11, 2005).

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BENEFICIARY EDUCATION AND COMMUNICATIONS 283 In the 7th scope of work (SOW), the Project Officer, the Regional Of- fice Communications Specialist, and the Government Task Leader assessed the success of each QIO on Task 2a on the basis of the following: The extent to which the QIOs used information from CMS or others to alter their activities to reach their goals, The timeliness of work plan submission, and The timeliness of reports and deliverables (CMS, 2002). Deliverables included: Submission of a work plan, Response to various information requests, and Maintenance of communications and planning tools (CMS, 2002). In the 7th SOW, the QIOs spent $33.5 million on Task 2a, which repre- sents approximately 4.2 percent of the QIO core contract budget (personal communication, C. Lazarus, March 17, 2005). Experiences with Public Reporting In telephone interviews with 20 QIO chief executive officers (CEOs), 11 CEOs independently raised concerns about public reporting. More than half of them noted difficulties with beneficiary understanding of publicly reported data and with the utility of those data for consumers when the consumers had a limited choice of providers offering Medicare services. Three CEOs commented specifically on problems in getting facilities in- volved in public reporting, one raised CMS's lack of timeliness as a draw- back to public reporting, and three discussed the positive aspects of public reporting. Seven of the 20 CEOs mentioned problems with the utility of publicly reported data for beneficiaries and how simplification and presen- tation by CMS might enhance their value. Three CEOs commented on how public reporting, credentialing, and accreditation help with culture change by driving competition among providers. The mixed reaction of CEOs is evident in the variety of comments below: "Most of the roll out of nursing home and home health data is too complex for beneficiaries. Also, the reality is that our nursing homes are community based, and it doesn't really matter what the quality is because you go to the one in the area where your family and support system [are]." "The nursing home formula needs to be simplified; there are too many measures. There is no incentive for a nursing home to change because

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284 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM TABLE 11.2 Home HealthRelated Calls to 1-800-MEDICARE Number of Calls Number of Calls Number of HHa Date Related to HHa Quality Related to HHa Compare-Related (mo-yr) Initiative Overview Quality Measures Calls Jan-04 9 11 142 Feb-04 9 3 101 Mar-04 4 4 70 Apr-04 2 1 90 May-04 4 1 72 Jun-04 5 4 110 Jul-04 NAb 4 86 Aug-04 9 2 144 Sep-04 2 1 109 Oct-04 8 3 107 Nov-04 9 1 124 Dec-04 8 6 133 Jan-05 10 4 156 Feb-05 9 3 131 Mar-05 10 3 156 Apr-05 25 4 NAb May-05 14 2 NAb NOTE: Data are as of June 10, 2005. aHH = home health; NA = not available. b SOURCE: QIONet Dashboard (accessed November 11, 2005). 300 250 200 HH Complaints 150 Total HH Calls 100 50 0 Jan-04 Mar-04 Jul-04 May-04 Sep-04 Nov-04Jan-05 Mar-05May-05 FIGURE 11.3 Home health care (HH)related calls to 1-800-MEDICARE (complaints versus total calls) (as of June 10, 2005). SOURCE: QIONet Dashboard (accessed November 11, 2005).

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BENEFICIARY EDUCATION AND COMMUNICATIONS 285 Number of Calls Number of Calls Concerned that Concerned that the HHa Compare HHa Compare is Number of HHa- Total Number Website is Down Moving Slowly Related Complaints of Calls 3 4 35 204 4 2 35 154 7 2 54 141 11 2 48 154 9 4 33 123 31 NAb 43 193 NAb NAb 44 134 NAb NAb 95 250 NAb NAb 77 189 NAb NAb 75 193 NAb NAb 74 208 NAb NAb 70 217 NAb NAb 86 256 NAb NAb 81 224 NAb NAb 87 256 NAb NAb 97 126 NAb NAb 68 84 the multitude of measures confuses the public and the public cannot judge what is a good and what is a bad nursing home." "Public reporting spurs culture change--facilities want to improve; otherwise, they might lose clients. Once the data are in front of them and they know they are so far behind they show great determination to turn around." "Fear of public reporting is what helps get hospitals and other pro- viders to focus on quality and realize that they have to do something." As of this writing, CMS had not defined any specific duties related to public reporting for the 8th SOW (CMS, 2005b). TASK 2B: TRANSITIONING TO HOSPITAL-GENERATED DATA In the 7th SOW, the overall purpose of Task 2b was to prepare hospi- tals for public reporting. Initiatives such as the National Voluntary Hospi- tal Reporting Initiative (now known as the Hospital Quality Alliance) and the Reporting Hospital Quality Data for Annual Payment Update moti-

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286 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM vated hospitals to collect their own data using standardized measure speci- fications (CMS, 2002, 2004a). The Hospital Quality Alliance is a public-private collaboration initi- ated by the American Hospital Association, the American Association of Medical Colleges, and the Federation of American Hospitals to begin the voluntary public reporting of certain quality measures by hospital provid- ers. They were later joined by others, including the Joint Commission on Accreditation of Healthcare Organizations, the National Quality Forum, the American Medical Association, and the U.S. Department of Health and Human Services. This collaborative effort led to the development of a starter set of quality measures to be reported on the Hospital Compare website and encouraged beneficiaries and others to use the site to make better- informed decisions about their hospital care. The overall goals were to pro- vide useful information to the public, align measures and reporting require- ments, and ease burdens on reporting hospitals (Providence Health System, 2005). The Reporting Hospital Quality Data for Annual Payment Update was a financial incentive established by the Medicare Prescription Drug, Im- provement, and Modernization Act of 2003 (P.L. 108-173) for prospective payment system hospitals to submit performance data (see Table A.1 in Appendix A). Hospitals submitted data to the QIO Data Warehouse using the CMS Abstraction and Reporting Tool (CMS, 2005a). Qualifying hospi- tals that did not submit such data received a 0.4 percent lower update to their prospective payment system rates than the hospitals that did report data. As of the third quarter of 2004, 96.29 percent of qualifying providers were submitting data on these measures (QIONet Dashboard, accessed November 11, 2005). CMS did not require hospitals to participate in the Hospital Quality Alliance to receive the update but encouraged their par- ticipation in both initiatives. In the 7th SOW, the QIOs helped hospitals learn how to collect their own data on these measures. To facilitate this, the QIOs: Assessed the capabilities of each provider; Provided technical assistance on the collection, processing, and re- porting of data; Performed data validation; Used data systems to collect confidential information; and Encouraged as many hospitals as possible to participate (CMS, 2002). In the 7th SOW, QIO contract performance success on Task 2b was based on:

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BENEFICIARY EDUCATION AND COMMUNICATIONS 287 The completion of surveys on hospitals' readiness for automated re- porting (30 percent of the total score), The proportion of hospitals implementing data abstraction systems (50 percent of the total score), and Hospital satisfaction with QIO support in data abstraction activities (20 percent of the total score) (CMS, 2002). The only deliverable for Task 2b was a survey of hospital readiness for automated reporting (CMS, 2002). In the 7th SOW, the QIOs spent $38.3 million on Task 2b, which rep- resents approximately 4.8 percent of the QIO core contract budget (per- sonal communication, C. Lazarus, March 17, 2005). TASK 2C: OTHER MANDATED COMMUNICATIONS ACTIVITIES In the 7th SOW, CMS required the QIOs to engage in many communi- cations activities to serve the beneficiary population, including: Establish a Consumer Advisory Council to advise the QIO, Maintain a toll-free telephone help line for beneficiaries, Publish an annual medical services review report (a report on all QIO review activities), and Reach out to hospitals and meet with medical and administrative staff (CMS, 2002). The success of these interactions is questionable. As discussed in Chapter 7, the Consumer Advisory Council has only an advisory role on the main board and therefore may not have much of an impact in directing consumer needs. Also, studies of the effectiveness of Medicare's main toll-free number for beneficiaries (1-800-MEDICARE) as well as of carrier call centers re- veal many problems. A July 2004 study by the Government Accountability Office found that only 4 percent of 300 policy-related calls made to carrier call centers received correct and complete answers (GAO, 2004a). In a De- cember 2004 study by the Government Accountability Office, callers to 1- 800-MEDICARE asked questions about eligibility, enrollment, and ben- efits. Only 61 percent of 420 callers received accurate answers (GAO, 2004b). The remaining answers were either inaccurate (29 percent) or un- able to be provided (10 percent). Also in 2005, the Office of the Inspector General of the U.S. Department of Health and Human Services surveyed 305 callers to 1-800-MEDICARE and found that 84 percent of callers were satisfied overall (DHHS, 2005). However, 44 percent of callers related dif- ficulty in accessing information because of difficulty with the telephone system, the lack of a full answer, or the speed of the response. Both of these

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288 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM studies recommend that CMS improve its help line organization and man- agement. No information on consumer satisfaction with the QIOs' indi- vidual help lines was readily available. Box 11.1 presents a template used by many QIOs for their Annual Medical Services Review Reports. These reports relate to case review activi- ties (see Chapter 12). In the 7th SOW, the Project Officer determined each QIO's success on Task 2c on the basis of the following: Establishment and use of a Consumer Advisory Council (see Chapter 7), Broadening of consumer representation on the QIO board of directors, Operation of a successful consumer help line (with success based on the findings of surveys of consumer satisfaction), and Production of an annual medical services review report (see Box 11.1) (CMS, 2002). Deliverables included: Submission of a plan for the Consumer Advisory Council, Tracking performance of the help line, and An annual medical services review report (CMS, 2002). CMS has not defined deliverables or evaluation plans for communications or beneficiary education activities because these activities are defined on a limited basis within other tasks (see Chapter 12). In the 7th SOW, QIOs spent $32.4 million on Task 2c, which repre- sents approximately 4.1 percent of the QIO core contract budget (personal communication, C. Lazarus, March 17, 2005). ROLE OF QIOS IN BENEFICIARY EDUCATION: TELEPHONE INTERVIEWS Nineteen QIO CEOs responded to questions about whether beneficiary education added value to quality improvement efforts and whether this func- tion should continue. Almost three-quarters (14 of the 19 CEOs) favored continuation of this function. One of the 19 CEOs was unsure of its value because he believed that it depended on what CMS values, and the remain- ing 4 of the 19 CEOs thought that their QIOs could be successful without beneficiary education. One CEO who favored beneficiary education thought that this function could be done at the discretion of the individual QIO.

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BENEFICIARY EDUCATION AND COMMUNICATIONS 289 BOX 11.1 Annual Medical Services Review Report "Annual Medical Services Review Report: State: Name of QIO: Time Frame: A. Beneficiary Complaints Under Medicare law, Quality Improvement Organizations (QIOs) review complaints about the quality of care that Medicare patients receive. The complaints come from Medicare patients and/or their representatives. In reviewing a complaint, the QIO looks at the services a patient received and decides whether those services met standards of health care that are commonly accepted by physicians and others in the medical community. "Quality of care complaints may involve more than one concern, due to the following: (1) more than one quality of care concern in a single set- ting; (2) the same quality of care complaint for a single patient episode of illness involving multiple settings and/or providers; (3) or more than one quality of care concern involving more than one setting and/or provider. For example, a Medicare beneficiary complaint related to a hospital stay might include several different quality of care concerns or a beneficiary who was hospitalized and then moved into a skilled nursing facility or other outpatient hospital setting might have the same quality of care con- cern occur in each type of setting. Consequently, for a specific Setting or Provider type, the number of quality of care concerns confirmed by the QIO may exceed the number of beneficiary cases reviewed. "Beneficiary Complaint Cases: Number and Review Results Number and Rate Review Results Total cases reviewed by the QIO: Cases with confirmed quality concern: Cases per 10,000 Part A Medicare Cases without confirmed quality beneficiaries: concern: Cases in process (without completion date): NOTE: Individual cases may involve more than one setting and/or provider. continues

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290 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM BOX 11.1 Continued "Complaint Cases with Confirmed Concerns: The Setting or Provider Number and Percent of Confirmed Concerns for the State Total Number Care Setting or Care Provider of Concerns Number Percent Hospital Skilled Nursing Facility (SNF) (includes SNF, swing, and swing critical access) Home Health Agency Medicare Advantage Physician Other Provider NOTE: Individual cases may involve more than one setting and/or pro- vider." "Complaint Cases with Confirmed Concerns: Type of Problem The numbers below represent only complaints by beneficiaries or their representatives. They do not include any other QIO reviews of medical services. Number/Percentage of Confirmed Concerns Number of Percent of Total Type of Concern Total Number Confirmed Confirmed Confirmed of Concerns Concerns Concerns Inappropriate or unnecessary services Inappropriate setting Services with a confirmed quality concern

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BENEFICIARY EDUCATION AND COMMUNICATIONS 291 "B. Hospital Admission and Continued Stay Concerns Under Medicare law, QIOs review the need for inpatient hospital care. They help determine whether a patient received care in the proper place or `care setting.' This review may take place at two different times, either during or after a hospitalization. In the first instance, patients or their representatives ask the QIO to review a `Hospital Initiated Notice of Non- Coverage,' or HINN, in which the hospital informs a patient that either an admission or a continued stay in a hospital is not needed. In such cases, the QIO conducts an `immediate review,' whereby the QIO reviews the case (within 2 working days following the beneficiary's request for a pre- admission or admission HINN and within 30 days for review after dis- charge or when the beneficiary was not admitted to the hospital) and issues either a denial notice or a notice explaining that the care would be, or is, covered. In other cases where a hospital issues a HINN, but the patient does not immediately ask for a review, the QIO automatically reviews the case after the fact in what is called `retrospective review.' In all reviews, the QIO staff looks carefully at the patient's medical record to decide if an admission or continued stay is/was needed. "Beneficiary Notice Reviews Review Results Appropriate Inappropriate Cases Cases Type/Timing Number (Agree with (Disagree of Review of Cases notice) with notice) Notice of Non-coverage FFS Preadmission Notice Concurrent Immediate Review Notice of Non-coverage FFS Preadmission Notice Nonimmediate Review Notice of Non-coverage FFS Admission Notice Concurrent Immediate Review Notice of Non-coverage FFS Admission Notice Non-immediate Review Notice of Non-coverage Continued Stay Notice continues

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292 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM BOX 11.1 Continued Review Results Appropriate Inappropriate Cases Cases "Type/Timing Number (Agree with (Disagree of Review of Cases notice) with notice) Immediate Review-- Attending Physician Concurs Notice of Non-coverage Continued Stay Notice Concurrent Non-immediate Review Notice of Non-coverage Continued Stay Notice-- Attending Physician Does not Concur Notice of Non-coverage Continued Stay Retrospective Notice of Non-coverage Retrospective Monitoring Review NODMAR Immediate Review MA MA Appeal Review (CORF, HHA, SNF)" SOURCES: Georgia Medical Care Foundation (2005), Texas Medical Foundation (2005), and OMPRO (2005). Two CEOs mentioned the indirect benefits of beneficiary education activities: "If you go to the media with just the professional side of the story, you wouldn't get any play; the beneficiary story gets the front page" and "Beneficiary education gives meaning to my staff by reinforcing the meaning of their work--quality of care for patients. If you continually only talk about systems of care, the work becomes estranged from the patient." The reasons given for questioning the value of beneficiary education activities included the belief that limited funding is best spent on providers, that other groups could perform the function, and that most of the issues are too complicated for consumers. The one CEO who was unsure said continuation depended on what CMS wants QIOs to be accountable for:

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BENEFICIARY EDUCATION AND COMMUNICATIONS 293 "Are we trying to have a more satisfied beneficiary pool or are we trying to improve the value of health care? But there are some projects where involv- ing beneficiaries would be beneficial." Leveraging Education Funding Among the 14 CEOs who favored continuing beneficiary education activities, three added that although they thought that this function should continue, the amount of money available allows the QIOs to do only a meager amount of education and that they did less education during the 7th SOW than during the 6th SOW. Another CEO said that working with ben- eficiaries does not have to be expensive; however, the costs may depend on the nature of the projects done with beneficiaries. Seven of 19 respondents gave examples of how they leveraged their resources for beneficiary education by working with other groups in the community and statewide. These groups, in turn, communicate informa- tion on health and beneficiary rights to their memberships. In addition, some do the actual work of setting up influenza and pneumonia immuniza- tion clinics and support other QIO projects on issues like screening for depression and heart health. Two CEOs mentioned that they include ben- eficiaries in their work by having them on advisory councils for each of their tasks. Without involving and educating beneficiaries, the QIOs would "lose the pulse of what is on consumers' minds." Need to Increase Beneficiary Education Seven of the 19 CEOs argued for increased funding for beneficiary edu- cation activities. Three CEOs underscored their comments by saying that outreach to beneficiaries in underserved communities is essential in making change: Statements included, "We need to educate them to get better care and to take better care of themselves" and "As QIOs work to change sys- tems and have more of a focus on chronic versus acute care, the need for educating consumers on patient self-management will only grow" because of the inability of physicians to spend sufficient time on education and phy- sician shortages in some areas. QIO SUPPORT CENTERS IN THE 7TH AND 8TH SOWS 7th SOW Several QIO Support Centers (QIOSCs) collectively support the com- munications and beneficiary education activities of the 7th and 8th SOWs. First, Qualis Health (under its contract as the QIO for Washington State)

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294 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM acted as the lead for the Communications QIOSC, along with assistance from Primaris (Missouri's QIO) as a subcontractor. The Communications QIOSC coordinated strategic planning for all communications activities, including national initiatives and methods that promote the QIO program. Another QIOSC strongly involved with communications activities is the Interventions QIOSC (run by the Iowa Foundation for Medical Care, Iowa's QIO), which supports the Medicare Quality Improvement Commu- nity (MedQIC) website (www.medqic.org). MedQIC (see Chapter 13) is a public website, available to both consumers and providers, that displays information about the QIO program and allows the sharing of knowledge. For providers, MedQIC presents specific stories and tools submitted by all QIOs on effective intervention programs for each of the task areas. For consumers, MedQIC supplies contact information for all the QIOs, but most of the website's content is aimed at providers or staff working in the quality improvement arena. The MedQIC website underwent a major struc- tural overhaul in the 7th SOW. Version 2.0 was released in March 2005, and as of this writing, version 2.1 was scheduled for a November 2005 release (personal communication, J. Kelly, September 6, 2005). The rede- sign includes a new architecture and framework so that it is coordinated with the activities of the 8th SOW. In the 8th SOW, MedQIC strives to increase public awareness of MedQIC, including a collaboration with the Communications QIOSC and the American Health Quality Association. Additionally, the Iowa Foundation for Medical Care supported other communications activities of the 7th SOW and held contracts to serve as a QIOSC for the following topic areas: outpatient data, hospital data collec- tion, and the Standard Data Processing System (see Chapter 13). Many of the other task-specific QIOSCs participated in beneficiary edu- cation activities during the 7th SOW through the supply of materials for providers to distribute to their patients, but CMS did not specifically desig- nate a single QIOSC for beneficiary education. 8th SOW In the 8th SOW, the QIOSC redesign (see Chapter 7) creates some re- structuring of the QIOSCs' supporting communications and beneficiary education activities. Again, all task-related QIOSCs provide some degree of support to these interactions. Qualis Health continues as the Communica- tions QIOSC in the 8th SOW, with Primaris continuing as a subcontractor. The Iowa Foundation for Medical Care continues its data-related activities under separate, restructured QIOSC contracts: the Hospital-Data Report- ing QIOSC, the Outpatient Data QIOSC, the Data Reports QIOSC, and the MedQIC QIOSC. The Health Services Advisory Group (Arizona's QIO)

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BENEFICIARY EDUCATION AND COMMUNICATIONS 295 supports communications activities as the new Measures Management QIOSC. SUMMARY This chapter has discussed issues related to the communications and beneficiary education activities of the QIO program. The following are some of the main themes of this chapter, which are reflected in the findings and conclusions presented in Chapter 2: QIOs have significant experience with the collection of data for per- formance measures and the promotion of publicly reported information. Little evidence exists to prove the effectiveness of QIOs' outreach to beneficiaries. The numbers of consumer visits to websites and the numbers of calls referred to the QIOs by Medicare are relatively low compared with the size of the entire beneficiary population. Studies have shown significant problems with CMS's main beneficiary help line (1-800-MEDICARE). Successive SOWs have had a decreasing direct-to-beneficiary role for the QIOs. In general, both CMS and the QIOs view providers as their pri- mary customers. Beneficiary education most often occurs indirectly through provid- ers as part of quality intervention plans or in partnership with local com- munity organizations whose primary focus is on beneficiary concerns. REFERENCES CMS (Centers for Medicare and Medicaid Services). 2002. 7th Statement of Work (SOW). [Online]. Available: http://www.cms.hhs.gov/qio [accessed April 9, 2005]. CMS. 2004a. The Quality Improvement Organization Program: CMS Briefing for IOM Staff. [Online]. Available: http://www.medqic.org/dcs/ContentServer?cid=1105558772835& pagename=Medqic%2FMQGeneralPage%2FGeneralPageTemplate&c=MQGeneralPage [accessed December 26, 2005]. CMS. 2004b. Quality Improvement Organization Manual. September 16. [Online]. Available: http://www.cms.hhs.gov/manuals/110_qio/qio110index.asp [accessed May 11, 2005]. CMS. 2005a. Hospital Quality Alliance: Improving Care Through Information. [Online]. Available: http://www.cms.hhs.gov/quality/hospital/HQAFactSheet.pdf [accessed April 25, 2005]. CMS. 2005b. 8th Statement of Work (SOW). [Online]. Available: http://www.cms.hhs.gov/ qio [accessed April 9, 2005]. DHHS (U.S. Department of Health and Human Services, Office of Inspector General). 2005. Medicare Beneficiary Telephone Customer Service. Washington, DC: U.S. Department of Health and Human Services. GAO (U.S. Government Accountability Office). 2004a. Medicare Call Centers Need to Im- prove Responses to Policy-Oriented Questions from Providers. Washington, DC: U.S. Government Printing Office.

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296 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM GAO. 2004b. Accuracy of Responses from the 1-800-MEDICARE Help Line Should Be Im- proved. Washington, DC: U.S. Government Printing Office. Georgia Medical Care Foundation. 2005. Annual Medical Services Review Report, Georgia, Georgia Medical Care Foundation. [Online]. Available: http://www.gmcf.org/about/pub- lications/Annual_Report_2004.pdf [accessed May 18, 2005]. OMPRO (Oregon Medical Professional Review Organization). 2005. Annual Medical Ser- vices Review Report, Oregon, OMPRO. [Online]. Available: http://www.ompro.org/ downloads/annual_reports/0304MedQofCAnnualReport.pdf [accessed May 18, 2005]. Providence Health System. 2005. The History of the Hospital Quality Alliance. [Online]. Avail- able: http://www.providence.org/alaska/quality/hqa_history.htm [accessed July 14, 2005]. Texas Medical Foundation. 2005. Annual Medical Services Review Report, Texas, Texas Medi- cal Foundation. [Online]. Available: http://www.tmf.org/publicationsMedicareAnnual Report2004.pdf [accessed May 18, 2005].