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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
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-
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
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
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
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
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
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
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-
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
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;
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.
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
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).
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
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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