Medicare's Quality Improvement Organization Program Maximizing Potential (2006) / Chapter Skim
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7 Structure and Finances
7 Structure and Finances
Pages 160-191
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97-248) modified and extended existing laws and regulations to create the current Quality Improvement Organization (QIO)
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STRUCTURE AND FINANCES 161 Physician-Sponsored and Physician-Access Designations To be eligible to compete for a QIO contract, an entity must meet certain criteria for designation as either a "physician-sponsored" or a "physician-access" organization (CMS, 2004b)
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. The web-based data collection tool also asked the individual QIOs about Baldrige National Qualitytype awards.
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HEDIS = Health Plan Employer Data and Information Set; HIPPA = Health Insurance Portability and Accountability Act of 1996; ISO = International Standards Organization; URAC = Utilization Review Accreditation Commission. aHEDIS is a set of standardized measures used to compare performance of managed care plans.
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The reported average length of employment among all employees ranged from 1.32 to 10.00 years, with a mean of 5.97 years. Examination of employee turnover within the QIO program is important, especially in light of the new priorities of transformational change in which the employee turnover rate is used as a measure of success.
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STRUCTURE AND FINANCES 165 development. A majority of the CEOs rated their leadership teams as demonstrating each of the leadership competencies to a "substantial" extent.
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did not anticipate the need for additional board expertise for the 8th SOW. Of the seven CEOs who foresaw such a need, three specified expertise in home health care in particular.
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. Professionals with backgrounds relevant to the tasks required in the 7th SOW other than hospital quality improvement -- executives or managers in nursing homes and home health care agencies -- were included on relatively few boards (28 and 2.56 percent, respectively)
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168 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM half of the organizations. Ten of 41 boards contained individuals with only two different types of professional backgrounds, although there was considerable variety in the second of the two backgrounds represented across the organizations (the common one being physicians)
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. More than half of the CAC members must be from organizations whose primary responsibility is protecting the interest of Medicare beneficiaries" (CMS, 2002:35)
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170 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM BOX 7.1 Health Services Advisory Group's CAC Member Organizations AARP Arizona ABC Coalition Aging and Adult Administration Alzheimer's Association Area Agency on Aging Arizona Academy of Family Physicians The Arizona Center for Disability Law Arizona College of Public health Arizona Health Care Cost Containment System Arizona Latin-American Medical Association Arizona Medical Association Arizona Rural Health Association Consumers/Senior Community Activists Foundation for Senior Living Gold & Associates Governor's Advisory Council on Aging HSAG Board of Directors Inter-Tribal Council Agency State Health Insurance Assistance Program University of Arizona College of Medicine SOURCE: Health Services Advisory Group (2005)
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. In the 8th SOW, CMS may require a QIO to subcontract for Task 1d1 duties (assistance with information technology implementation in the physician practice setting)
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but did not recommend that physician-specific information be revealed. The disclosure of specific information was thought to be in opposition to the philosophy of peer review -- the use of root-cause analysis and improvement methodologies without penalty.
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A QIOSC can help QIOs decide how to recruit identified participants, serve a convening function for QIOs to communicate among themselves through monthly calls and listserves, and provide other technical support as needed. By also acting as a central clearinghouse of information, the QIOSC gathers information on the experiences of individual QIOs, including best practices, change concepts, clinical techniques, and guidelines that QIOs can apply to their own interventions.
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The topic or provider setting QIOSCs focus more specifically on certain tasks or provider settings and will use their expertise to customize the tem TABLE 7.3 QIOSCs in the 7th SOW Topic Area Name or Acronym State Nursing home NH QIOSC RI (CO is subcontractor) Home health HH QIOSC MD Hospital -- heart care (acute myocardial Heart Failure QIOSC CO infarction and heart failure)
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, · Hospital data reporting, · Physician office (which has a coordinating role for office setting, Doctor's Office QualityInformation Technology, and the underserved population) , · Underserved, · Outpatient data, · Pharmacy (Task 1d3, which is related to the Medicare Part D prescription drug benefit)
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. TABLE 7.4 QIOSCs in the 8th SOW Topic Area Name or Acronym State Nursing home NH QIOSC RI Home health HH QIOSC WV Hospital -- interventions Hospital Interventions QIOSC OK Hospital -- data reporting Hospital Reporting QIOSC IA Physician office Physician Office QIOSC VA Underserved UQIOSC TN Outpatient data Outpatient Data QIOSC IA Pharmacy (Task 1d3)
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Working with External Stakeholders QIOSCs are able to work with external stakeholders (e.g., national professional associations) and other players in the quality improvement field (e.g., the Joint Commission on Accreditation of Healthcare Organizations)
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178 MEDICARE'S QUALITY IMPROVEMENT ORGANIZATION PROGRAM Recommendations for Improvement The QIO CEOs made specific recommendations for improving the QIOSCs, including: · Improve the timeliness of the QIOSC response to QIOs and deal with underlying problems with CMS responsiveness and coterminous contracting of QIOSCs and QIOs on tasks (15 CEOs)
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. For the 7th SOW, the estimated total obligations at the end of calendar year 2004 for the entire QIO program were $1,154.3 million.
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Additionally, it is difficult to make a direct comparison of spending on specific areas between the 7th and the 8th SOWs because of a shift of the categories in which the spending is attributed. Although the overall funding for the QIO program has increased with each successive SOW, Table 7.6 shows that program funding has become a smaller percentage of the overall Medicare budget since the 6th SOW.
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While the majority of the total expenditures went toward these statewide-level activities, work with the identified participants was more intense with fewer providers. For example, as shown in Table 7.8, QIO work with nursing homes in the 7th SOW had a monthly cost of $170.97 for each provider in the state or jurisdiction.
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However, the QIOs' focused work with a subset of nursing homes cost $350.35 per identified participant, even though this work only accounted for 31 percent of total expenditures for this subtask. These data are significant since statewide work accounted for the majority of the total expenditures, but work with identified participants for nursing homes and physicians' offices had higher expenditures per provider.
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STRUCTURE AND FINANCES 183 TABLE 7.9 Percentage of Total Revenue from the Core Contract of the 7th SOW Total Proportion of Revenue Number of Organizations, from Core Contract Holding QIO Contracts for the 7th SOW <10 percent 0 1019 percent 1 2029 percent 4 3039 percent 6 4049 percent 4 5059 percent 4 6069 percent 3 7079 percent 6 8089 percent 5 9099 percent 4 100 percent 2 SOURCE: IOM committee web-based data collection tool (n = 39 organiza tions)
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Estimated obligations for support contracts in the 7th SOW (as of April 2004) were $243.5 million, or approximately 21.1 percent of the total QIO program budget (personal communication, C
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After FMIB approval, the FMIB chair presents the planned budget to the CMS Executive Council for final approval. Most funded projects have existed in previous SOWs and continue to support the QIO program as a whole (personal communication, C
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Their activities included the services indicated in Table 7.10 within and outside of their home states. Forty-nine QIOs reported on their 3-year strategic plans for services to non-CMS clients.
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Data analysis 43 81.13 25 47.17 Quality improvement projects or 40 75.47 22 41.51 consulting Medical necessity reviews 39 73.58 29 54.72 Medical record abstraction 37 69.81 24 45.28 Independent external review 34 64.15 25 47.17 Utilization management 32 60.38 23 43.40 Data management 31 58.49 19a 35.85 Diagnosis-related group coding and 29 54.72 18 33.96 validation Project management 27 50.94 16 30.19 Continuing education 26 49.06 12 22.64 Health or clinical services research 25 47.17 1b 1.89 HEDIS-related activities 21 39.62 13a 24.53 Software development 21 39.62 12a 22.64 Claims validation 20 37.74 10 18.87 Service to public reporting efforts 17a 32.08 6a 11.32 Consumer and patient surveys 17 32.08 7 13.21 Fraud and abuse investigation 15 28.20 6 11.32 Other 14a 26.42 13a 24.53 Case management 11 20.75 10 18.87 Disease management 11 20.75 13 24.53 Health information exchange networks 10 18.87 5 9.43 Facility accreditation 8 15.09 3 5.66 Credentialing 7 13.21 4 7.55 Discharge planning 7 13.21 6 11.32 NOTE: HEDIS = Health Plan Employer Data and Information Set. aOne respondent selected "prefer not to answer/information not available." bEight respondents selected "prefer not to answer/information not available." SOURCE: IOM committee web-based data collection tool (n = 53 QIOs)
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. SUMMARY This chapter has discussed issues related to the overall structure and financing of the QIO program.
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STRUCTURE AND FINANCES 189 TABLE 7.12 Sources of Nonfederal Revenue in the 7th SOW Number Total Number of Reporting Organizations Responding Source "Yes" to This Questiona Medicaid program, own state 26 37 Other state agencies, own state 20 34 Medicaid programs, other states 14 32 Managed care organizations 12 32 Other private-sector health care organizations 12 30 Other private-sector non-health care organizations 8 34 Universities or colleges 7 28 Hospitals 7 30 State or local foundations 4 27 Local governments, own state 3 27 National foundations 3 28 Nursing homes 1 26 Physicians or physicians' groups 1 27 aDepending on the source, 4 to 15 organizations chose not to report on the source(s) of their nonfederal revenues.
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Overall, however, the QIOs believe that the assistance provided by the QIOSCs was not timely enough and that the QIOSCs were hindered from being innovative. · The QIO program's budget is small relative to total Medicare spending on services (0.10 percent)
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2004a. The Quality Improvement Organization Program: CMS Briefing for IOM Staff.
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