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Medicare Enhances Quality Improvement Organization Program Oversight


Email Alert

September 1, 2006

To more effectively promote high quality, efficient, and person-centered care for beneficiaries, the Centers for Medicare & Medicaid Services (CMS) today outlined actions the agency is taking to enhance oversight and evaluation of the Medicare Quality Improvement Organization (QIO) Program. The Report to Congress was developed as a result of intensive CMS review and a recent Institute of Medicine report.

"The QIO program is a cornerstone in our efforts to improve the quality and efficiency of care delivered to Medicare beneficiaries," said CMS Administrator Mark B. McClellan, M.D., Ph.D. "QIOs have had a positive impact on the quality of health care in America, and with enhanced oversight and accountability, and new initiatives to improve transparency and care, they will do more to support better care and lower costs.

QIOs are organizations with state-level responsibilities under contract with CMS that, by statute, are responsible for a range of key tasks in support of the Medicare program. QIOs work to improve quality of care, measure and reduce the incidence of improper Medicare fee-for-service inpatient payments, address beneficiary complaints and patterns of potentially substandard care, and offer mediation services to help address poor communication issues between health care providers and patients.

One key issue in the Report responds to recommendations on reforming the oversight and governance of the QIO program. Under CMS' existing authority in the current contracting cycle, CMS is strengthening its financial oversight by requiring each contractor to have a more independent advisory board, charged with review of compliance, conflict of interest, ethics and program integrity. Boards will be required to evaluate the structure of each state-based QIO contractor and its relationship with providers and stakeholders within the state.

In addition, CMS is taking steps to improve beneficiary awareness of the complaint and appeals process available through QIOs, to make sure that beneficiaries are familiar with this important resource and can use it when they need it. In particular, CMS is undertaking education and outreach efforts that the QIOs will be expected to leverage to ensure that beneficiaries better understand how and when to file complaints, and to ensure that beneficiaries who file complaints understand the result and actions that will be taken to prevent the problems from occurring in the future.

Also in response to recommendations and to the Administration's recent transparency initiative, the QIOs are enhancing their efforts to achieve better quality care by providing better information on quality and costs to consumers and providers. Building on these national initiatives to provide better information on hospital and ambulatory care, a QIO pilot project will expand information available to Medicare beneficiaries on the quality of service provided by Medicare providers.

Under this Medicare pilot project, QIO subcontractors will aggregate and analyze data on services furnished to patients with private insurance, Medicaid, and Medicare coverage to produce comprehensive indicators on the quality of the services furnished by Medicare providers in these locations. Consumers, private insurers, employers, and state governments are working together in this project, which will produce information that will allow Medicare beneficiaries to make more informed coverage choices, and that will also be available to consumers of health care generally.

"By updating the QIO program to reflect the most promising new approaches to develop and use information on quality, we are taking another step in our efforts to empower consumers to find better care and better value," said Dr. McClellan. "Building on their current activities, these actions enable us to better utilize them in helping us achieve a transformed, modernized, and less costly health care system."

The QIOs will also provide increased technical support for payment reforms to pay providers based on higher quality and lower overall costs of care. As part of performance-based payment pilot programs, the QIOs will continue to provide technical assistance for providers who want to improve in these measures, particularly providers with underserved and disadvantaged populations. In addition, QIOs will continue to provide the national infrastructure for reporting, which includes data collection, submission, validation and results reporting, for activities such as the annual payment update for hospital reporting on quality measures, and data warehousing used in nursing home and home health agency reporting.

"We are committed to continuing our efforts to ensure that the QIO program is focused, structured, and managed so as to maximize its ability for creating value," said Barry Straube, M.D., CMS Chief Medical Officer and Director of the Office of Clinical Standards and Quality. "These efforts will enable us to support the agency's broader initiatives to provide transparency for beneficiaries and create performance-based payment programs for providers."

The report can be found at:

We would like to thank Hal McCard (Chaffe McCall LLP, New Orleans, LA) for providing this email alert.

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