Medicare's Quality Improvement Organization Program Maximizing Potential (2006) / Chapter Skim
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4 Improving Quality and Performance Measurement by the QIO Program
4 Improving Quality and Performance Measurement by the QIO Program
Pages 102-119
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From page 102... ...
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 beneficiaries has gradually been improving over time.
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From page 103... ...
is creating partnerships with other government, health professional, and consumer stakeholder groups (such as the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the Nursing Home Quality Initiative, the Institute for Healthcare Improvement, and the American College of Surgeons) to develop measures and new initiatives designed to promote quality (CMS, 2005b)
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From page 104... ...
. 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, aggregating, validating, and analyzing quality measurement data.
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From page 105... ...
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 Medicare 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.
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From page 106... ...
Under the 7th scope of work (SOW) , QIOs offered all hospitals, home health care agencies, and nursing homes assistance with the collection 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.
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From page 107... ...
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 efforts 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)
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From page 108... ...
While the committee recommends that the QIOs focus on helping providers engage and educate beneficiaries, not on providing direct education to individual beneficiaries or patients, this recommendation is in no way intended to diminish the importance of beneficiary education as an aspect of patient-centered care. Indeed, the committee believes 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.
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From page 109... ...
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)
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From page 110... ...
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.
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From page 111... ...
· 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.
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From page 112... ...
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 activities and less responsibility for complaints, appeals, and case reviews.
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From page 113... ...
Internet searches for "[state] medical complaints" produce a variety of organizations, such as the state department of health or state department of insurance, the nursing home ombudsman for the state, the state medical society, and usually the QIO.
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From page 114... ...
Overall, however, the provision of confusing or incomplete information and the lack of a central location where beneficiaries can lodge complaints 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.
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From page 115... ...
The fiscal intermediaries for Medicare might be the type of organization that could logically conduct 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.
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From page 116... ...
. The QIO program annually screened and abstracted a random sample of approximately 38,000 hospital claims during the 7th SOW, the mean payment error rate at the beginning of the 7th SOW was 4.33 percent (CMS, 2005a)
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From page 117... ...
· 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 program is best positioned to provide that assistance.
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From page 118... ...
Adequate evaluations of the accomplishments of the QIO program as a whole and of individual interventions will also depend on CMS management. The results of those evaluations should influence future program directions and funding, if any.
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From page 119... ...
Program 7th SOW and Re sults. PowerPoint Presentation to the Committee on Redesigning Health Insurance, June 13, Washington, DC.
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