Lawmakers balk at bigger role sought by Medicare quality groups

Washington -- Federal officials have high hopes for Medicare's quality improvement organizations and anticipate that they will play an integral role in quality reporting and pay-for-performance programs in the future. But QIOs might need to assuage some of their critics on Capitol Hill before they can get into position to become such key players.

In a recent letter, Senate Finance Committee leaders asked the Centers for Medicare & Medicaid Services whether QIOs truly are capable of bettering care for beneficiaries. These typically nonprofit organizations contract with the government to improve quality by providing technical support to physicians and others, and by investigating patient complaints against medical professionals.

Several nagging questions must be answered before QIOs should be allowed to have a larger part in Medicare, wrote Senate Finance Committee Chair Charles Grassley (R, Iowa) and Ranking Democrat Max Baucus (Mont.).

"If these organizations are spending inappropriately or failing to actually ensure quality in the Medicare system, those shortcomings have to be figured into any contract and payment agreements," Baucus said in a separate statement. "There are too many unknowns right now to make QIO commitments further into the future."

The lawmakers are concerned that some of these organizations may have too cozy a relationship with the physician practices, hospitals and others that they advise on ways to improve patient care. Because the QIOs also are tasked with looking into beneficiary complaints against some of those same entities, their desire to maintain good working arrangements with the medical personnel might interfere with their ability to investigate the charges fully.

Allegations that QIOs have spent federal funds on costly travel for their board members and other questionable expenses has raised the level of concern among the groups' critics. In addition, insufficient evidence exists to suggest that QIO assistance to doctors and others results in a measurable boost in quality of care, the senators said.

"If the problems were confined to financial improprieties and conflicts of interest, increased oversight would suffice," the letter states. "However, in addition to these potentially serious problems, there is still a need for more thorough evaluation of the QIOs' effectiveness in improving the quality of health care."

The Institute of Medicine also cited these possible conflicts of interest and lack of QIO assessment studies in a recent report on the organizations. The group recommended that CMS reassign complaint reviews to a smaller set of contractors and implement a system to gauge QIO performance.

Expanding QIO roles

The latest challenge from Capitol Hill comes at a time when the organizations and their congressional allies are looking into ways to broaden the domain of the groups and boost their federal funding to take on new jobs within Medicare.

The American Health Quality Assn., the organization that represents QIOs, has said that future adoption of quality reporting and performance-based payments for physicians and others is a prime example of an area in which the groups can be invaluable to Medicare. QIOs, many of which have boards that are dominated by physicians, would be in an ideal position both to help collect the quality information submitted by doctors and to advise them on ways to improve their performance.

"The QIOs can play a much more important role in helping providers and practitioners measure their own performance and then make appropriate improvements," said David G. Schulke, the AHQA's executive vice president. "To the extent that there's payment that rewards people for making improvements or for hitting a high level, then the QIOs can help them qualify for those additional payments."

AHQA recently submitted a letter to CMS Administrator Mark McClellan, MD, PhD, that outlined the legislative and regulatory changes necessary for QIOs to start moving down the path toward a broader and more effective role within Medicare. Part of this call to action would involve Congress approving a budget for the organizations that is more than five times what they currently receive from the federal government. The current three-year budget for the groups is set at about $1.2 billion.

Although Medicare has not yet responded to the strategy, CMS Acting Chief Medical Officer Barry Straube, MD, and other agency officials have agreed with AHQA's assertion that QIOs are good candidates to play an enhanced role in quality reporting efforts involving physicians and others.

In the meantime, as lawmakers and CMS continue to debate the merits of QIOs and their potential role in quality reporting, Schulke said his group would continue to answer critics such as Grassley and Baucus with numerous studies showing that quality improvements can be linked to the organizations' work with physicians and others.

But until the more comprehensive QIO assessment system called for by the IOM is put into place, the face-off could continue. Few controlled studies of the groups' effectiveness exist today, because Congress and Medicare officials did not originally set up the QIO program as a research endeavor, Schulke said.