Changes sought to tech rules for Medicare quality groups

Washington -- Physician practices in select states are being recruited by Medicare quality improvement organizations that are helping them adopt health information technology. But some stakeholders worry that new proposed government rules, if left unchanged, could confuse these efforts.

The Centers for Medicare & Medicaid Services recently proposed new rules for the nation's QIOs, which will contract with the agency for a new three-year term that starts in August 2005. The guidelines cover everything that the quality improvement groups do, from giving physicians advice on adopting disease management programs to promoting organizational changes within nursing homes that can lead to better patient outcomes.

As part of the free consulting services that they offer to physicians and other Medicare participants throughout the country, the firms are assisting doctors in implementing health information technology in an effort to optimize practice workflow, increase patient safety and lower costs to the federal government. The QIOs in Arkansas, California, Massachusetts and Utah are roughly halfway through a Medicare pilot project in which the groups are assisting small- to medium-sized physician practices that are good candidates for upgrading to electronic health records.

CMS anticipates that the initiative will serve as a framework for expanding such a service to one out of every 10 physician offices billing Medicare in each state.

The agency aims to broaden greatly the scope of responsibilities that QIOs will have in promoting IT innovations and demonstrating their usefulness through improved outcomes. Physicians who take advantage of the organizations' services will be asked to show that the assistance they receive is working, while QIOs will be required to secure specialized subcontractors that will shoulder some of the added work of helping doctors.

But both the physician community and the quality organizations themselves warn CMS that the way it plans to mandate more accountability and spread out the work may have serious problems.

The proposed strategy calls for comparing individual physician practices with each other in an effort to gauge the QIOs' effectiveness. Such a move would be counterproductive, wrote American Medical Association Executive Vice President Michael D. Maves, MD, in a comment letter on the CMS plan.

"Presently, there are limited and far from perfect means for assessing an individual physician's performance in relation to her or his peers," Dr. Maves stated.

On the requirement that QIOs seek the help of subcontractors, Dr. Maves said the Medicare agency must ensure that state medical associations and specialty societies are consulted during the hiring process to avoid a situation in which physicians are left unaware of who is in charge.

David Schulke, executive vice president of the American Health Quality Assn., which represents QIOs, takes a harder line against the subcontracting requirement.

"We believe that the proposed contracting methods will limit the effectiveness of QIOs, undermine the accountability that is the linchpin of performance-based contracting and significantly raise administrative costs -- remaking this successful program into one that accomplishes less at greater cost," he said. "Ultimately, we believe the proposed approach will create barriers to Medicare's success in achieving transformational change by burdening and unsettling stakeholders in the program."

Building from the ground up

But Antonio Linares, MD, medical director of Lumetra, the QIO serving California, believes the CMS strategy could help.

Quality organizations and physicians alike could benefit from the introduction of additional entities to assume a measure of the added work, he said. As long as the QIO remains the lead consultant and subcontracts with as few other firms as necessary, more choices could be beneficial, he said.

"Practices should have options to be able to select the most appropriate provider or service or vendor to address their needs as it relates to the electronic health record implementation," Dr. Linares said. "When a practice does require more intensive support, whether it be in a technical area or a practice management area, we should identify the services that best meet those needs."

Dr. Linares noted that even the initial process of deciding whether to go ahead with adopting an IT system for a physician practice consumes a large amount of time and resources. A subsequent decision to proceed entails many hours of work in choosing the right system, adjusting the office's organizational structure to accommodate it and making sure that the correct improvement data are being transmitted to Medicare officials.