Medicare's Quality Improvement Organization Program Maximizing Potential (2006) / Chapter Skim
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Part I--Introduction: 1 A Historical Perspective and the Current QIO Program
Part I--Introduction: 1 A Historical Perspective and the Current QIO Program
Pages 33-54
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First is an extensive study of the QIO program conducted for this project. It included a review of the history and various aspects of the program, based on data gathered from the Centers for Medicare and Medicaid Services (CMS)
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Included is the rationale for those recommendations, which is based on the findings and conclusions presented in Chapter 2 and the committee's prior recommendations as summarized in Chapter 3, as well as additional information. · Chapter 5 presents the committee's recommendations on the oversight of the QIO program by CMS.
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It focuses particularly on the QIO program from 2002 to 2005, the period evaluated in this report, and the next contract period, which is in tended to achieve quality improvements through activities that will transform systems, processes, and outcomes of care. The federal government's interest in ensuring the quality of health care for Medicare beneficiaries in the United States originated with an emphasis on detecting the overuse and inappropriate use of Medicare benefits (primarily for cost-containment purposes)
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) .2 HISTORY OF THE QIO PROGRAM Certain challenges must be addressed when one is evaluating a complex public program with a lengthy history that has evolved in response to shift 2CMS contracts with private organizations for QIO services in each state for 3-year periods.
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The evaluation must also be useful to various audiences: policy makers, those managing the program, those working in the program both at the federal level and in contractor organizations, and those providers and practitioners who do and do not participate in the program. The QIO program has existed in various forms for more than 35 years.
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Rather than comparing the present performance of the QIO program against earlier recommendations and current expectations, the committee decided to supplement its evaluation with an assessment of how the program might contribute to future quality improvement efforts. A key factor in this assessment was the above-noted adaptable nature of the Medicare quality assurance and improvement program and the ability of QIOs to respond to new demands and changes in each CMS contract.
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Nonetheless, the next section of this chapter describes selected elements of Medicare's quality programs from their beginning to the present contract period. An understanding of the QIO program's evolution can provide guidance for assessing the program's potential value in strengthening the quality improvement efforts of CMS and the role CMS could play in implementing the recommendations formulated in the recent IOM report Performance Measurement: Accelerating Improvement (IOM, 2006)
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. Utilization and Quality Control Peer Review Organizations In 1982, the Peer Review Improvement Act (P.L.
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99-509) extended some review activities to cover other settings, including skilled nursing facilities, home health care agencies, hospi
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However, the report concluded that certain priorities needed to be revised: quality review and assurance should be emphasized over utilization and cost control; PROs should pay more attention to average practice patterns than to outliers; and PROs should be more involved in health care settings beyond inpatient hospital care. Additionally, the IOM report noted the burdens on providers imposed by the PRO program, its lack of positive incentives and punitive attitude toward providers, the hostile perceptions of
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In 1992, the Health Care Financing Administration (HCFA) , the predecessor of CMS, implemented the Health Care Quality Improvement Initiative to move from targeting individual provider errors toward focusing on practice patterns and care outcomes at the institutional and national levels (Bhatia et al., 2000)
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The first project under the Health Care Quality Initiative was the Cooperative Cardiovascular Project, which was pilot tested in four states. This project focused on care for acute myocardial infarction in the hospital setting (Sprague, 2002)
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No summative evaluation was ever conducted. During the 5th SOW, in addition to case reviews and beneficiary education, PROs worked on both nationally defined and locally selected quality improvement projects in the areas of acute myocardial infarction, diabetes, and preventive care for breast cancer (see Table 1.2)
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Task 1 National HCQIP National HCQIP Projects in specific topic areas with standardized HCFA-directed projects indicators for each setting: · Statewide impact · AMI expected · Heart failure · Proportional · Pneumonia involvement of M+C · Stroke beneficiaries · Diabetes · Projects for: · Breast cancer AMI Diabetes Preventive care PRO-initiated cooperative projects Task 2 · PRO designs projects Three required local QI projects: based on local needs · Choose one indicator from Task 1 and show · Statewide impact reduction in a disparity in a disadvantaged group expected · Develop project in a setting other than acute care · Proportional hospital or M+C involvement of M+C · Develop a project for local needs beneficiaries Task 3 · Project must include QI projects with M+C plans measurable indicators · Each plan must annually implement two performance improvement projects: Beneficiary protection One on a topic of national interest, as selected by and information HCFA activities One selected by the plan on the basis of the needs · Education and of its enrollees outreach · Projects started each year continue as new projects · Hotline are added Task 4 Mandatory case review Payment Error Prevention Program Multiple categories Two projects required: including: · Unnecessary admissions · Beneficiary complaints · Miscoded DRG assignments · HINNs Task 5 · EMTALA review Other mandated activities · Cataract surgery · All mandatory case reviews assistants · Beneficiary outreach and education · Gross violations Task 6 · Hospital-requested Special studies higher-weighted DRG adjustments NOTE: AMI = acute myocardial infarction; DRG = diagnosis-related group; EMTALA = Emergency Medical Treatment and Labor Act; HCQIP = Health Care Quality Improvement
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National HCQIP Assisting providers with developing capacity for Projects in specific topic areas with and achieving excellence standardized indicators for each setting: Projects in specific topic areas with standardized · Nursing home indicators for each setting: · Home health · Nursing home · Hospital (AMI, heart failure, · Home health pneumonia, surgical infection) · Hospital (heart failure, pneumonia, AMI, · Physician office (diabetes, cancer, surgical infection)
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QIOs initiated some quality improvement projects for nursing homes, home health agencies, and organizations participating in Medicare+Choice (Table 1.2)
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The QIO program set national goals for each indicator, and each state's QIO had to comply with every task of the SOW, using a nationally consistent set of indicators and measures. Each QIO had discretion in determining how to carry out the required projects, but all had to meet the formal national targets, regardless of local demographics and provider differences.
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This effort sought to help beneficiaries and their families make informed choices, as well as to encourage nursing homes to improve upon the quality of care they delivered. CMS also initiated public reporting in home health care and hospital settings (CMS, 2004a)
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The remaining 32 percent of the total apportionment funds the QIOSCs; special studies conducted by selected QIOs; and support contracts to other entities for program operations, such as the data system for the whole QIO program. Many of the support contracts relate to broad issues of quality improvement in the Medicare program, such as the development of a series of consumer surveys of patient experiences.
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. In the 8th SOW, the QIO program's philosophy has changed, as the term "quality of care" has evolved to include the transformation of systems and processes, as well as the development of tools for improving care (Rollow, 2004)
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In this new phase, CMS and its QIO program aim to achieve transformational change, focusing on the overarching processes and systems of health care delivery instead of individual episodes of care to create a new culture and environment in which the ideals of quality of care can thrive. REFERENCES Bhatia AJ, Blackstock S, Nelson R, Ng TS.
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2002. Contracting for Quality: Medicare's Quality Improvement Organizations.
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