IOM report seeks sharper focus for Medicare quality improvement groups

Washington -- Medicare's quality improvement organizations need to get out of the business of investigating beneficiary complaints against physicians, says the Institute of Medicine.

A yearlong, congressionally mandated review of the nation's 41 QIOs found that the groups are uniquely positioned to play a vital role in improving the quality of care offered by doctors, hospitals and other Medicare players. But a requirement that these organizations also chase down individual beneficiaries' grievances about the quality of care they receive, review appeals for coverage and assess the appropriateness of Medicare claims only distracts them from their primary mission, the IOM said in its recent report.

"While we recognize the importance of the proper handling of beneficiary complaints and case reviews, these organizations have not yet realized their full potential to help health care providers meet the highest quality standards," said Steven Schroeder, MD, a health professor at the University of California, San Francisco, and chair of the committee that authored the report. "The role of QIOs should be to improve health care practice, rather than to supervise or regulate it."

QIOs conducted almost 3,000 complaint reviews between August 2004 and August 2005, the IOM stated.

The solution offered by the IOM, a nonprofit component of the National Academies of Science, is to relieve most of the quality improvement organizations of the burden of investigating patient charges of substandard care. By shifting this responsibility to a few national or regional contractors, Medicare could allow QIOs to focus on quality improvement rather than on quality assurance.

The typically nonprofit organizations, which contract with Medicare in all 50 states, the District of Columbia, Puerto Rico and the Virgin Islands, already spend most of their federal funding providing technical support to physicians and others in the interest of improving quality. A QIO might help a physician practice determine whether it could improve care by adopting an electronic medical record or a hospital system decide whether it should implement a disease management program.

Until the government better focuses the organizations' mission, their most promising contributions to health care will continue to be held back by inherent conflicts of interest that limit their effectiveness across the board, the IOM said.

Many doctors will continue to view QIOs primarily as federal regulators and avoid working with them on beneficial quality improvement projects, the report says.

On the flip side, the organizations, which typically have boards dominated by physicians, could be wary of aggressively investigating quality complaints against doctors and others with whom the QIOs want to maintain good working relationships.

But the quality groups warn that the IOM's recommendation has a big downside.

To separate the two efforts and hire contractors whose sole purpose is to enforce Medicare standards would force doctors to relive the days of the much-maligned peer review organizations, the predecessors to QIOs, said Jonathan Sugarman, MD, MPH, president and CEO of Qualis Health, the QIO serving Idaho and Washington. "There is some danger to recreate that by unlinking the accountability piece and the quality improvement and technical assistance piece," he said.

The organizations believe that they can serve both doctors and beneficiaries to the best extent possible by continuing to have one firm provide not only a reason for a physician to improve his or her quality but also tangible advice on how to do so.

Some in Congress might not be convinced. After the report's release, Senate Finance Committee Chair Charles Grassley (R, Iowa) wrote a letter to the Centers for Medicare & Medicaid Services reiterating his concerns that QIOs place a low priority on investigating Medicare patient complaints and should perhaps be relieved of these duties.

CMS, which must approve some of the recommendations offered by the institute, is open to several of the proposed reforms. The agency considers reassigning the Medicare complaint, appeals and review process to a small group of regional contractors to be a promising way to improve the QIO program, said Barry Straube, MD, the agency's acting chief medical officer.

Pay-for-performance awaits

The shortcomings in the current system are not inconsequential when it comes to the future of Medicare's quality improvement organizations, the IOM said. As Congress and the Bush administration continue to promote quality reporting and eventually pay-for-performance in Medicare, the organizations can use the relationships they have forged between the government and program participants to help ensure that this transition goes as smoothly as possible.

"If the QIO program were repositioned and strengthened to fulfill its potential, it could support provider efforts to improve the quality of care received by Medicare beneficiaries and help support a national performance measurement and reporting system," the report said.

QIOs would play two major roles in this process under the scenario envisioned by IOM. Not only could they help get physician practices and hospitals up to speed on reporting quality measures, but they also could use their resources to process all the data to help gauge performance.

Once they catch onto the QIO program's role in the process and the help that its contractors could offer in the quality reporting arena, doctors and others will come running to use them, said Gail Wilensky, PhD, a senior fellow at Project Hope in Bethesda, Md., and an IOM panel member. "There's just nothing like payment to focus providers' attention."