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Medicare News
Rules Strengthened for Medicare Quality Improvement
Organization Program
CMS wants stronger advisory boards, better
beneficiary communications
September 6, 2006 Medicare Quality Improvement
Organization contractors will be required to have independent advisory
boards and to help assure beneficiaries better understand how and when
to file complaints, and understand the result and actions that will be
taken to prevent the problems from occurring in the future. These
actions are part of an effort by the Centers for Medicare & Medicaid
Services "to more effectively promote high quality, efficient, and
person-centered care" for people in Medicare.
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A CMS news release today outlined actions the
agency is taking to enhance oversight and evaluation of the QIO
Program. These actions are part of a Report to Congress, which was developed as a result of intensive
CMS review and a recent Institute of Medicine report.
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.
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, who has said
he plans to leave the agency within weeks.
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."
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
Administrations 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, according to CMS.
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 agencys
broader initiatives to provide transparency for beneficiaries and create
performance-based payment programs for providers.
The report can be found at:
http://www.cms.hhs.gov/QualityImprovementOrgs/
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