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As Grassley Investigates, QIOs Claim Progress in Narrowing Disparities

MAY 22, 2006 -- As the Medicare program puts the finishing touches on recommendations to Congress about the future role and funding levels for "quality improvement organizations," Sen. Charles E. Grassley, R-Iowa, and the organizations themselves are jockeying to mold Capitol Hill perceptions of the programs.

QIOs, on the one hand, are seeking to remind lawmakers of their reputation as the mainstays of the nation's two-decade-old quality improvement movement in health care. Grassley, on the other, aims to spotlight recent executive salary, travel, and entertainment expenses in the industry that in his view raise doubts about its stewardship of Medicare dollars.

At a press briefing Monday sponsored by the lobby that represents QIOs, several of the organizations called attention to recent projects they say narrowed racial and ethnic disparities in health care. The data aim to allay doubts raised by Grassley about how well QIOs are doing their jobs.

Meanwhile, Grassley, who chairs the Senate Finance Committee, has sent a letter to the QIO's lobby, the American Health Quality Association (AHQA), raising more questions about QIO expenditures, including $123,000 in banquet charges at a three-day meeting last June sponsored by another organization called the Tri-Regional QIO conference. AHQA said it wasn't responsible for those particular charges and that its outlays complied with federal regulations.

"We're investigating how these contractors conducted business in order to protect Medicare dollars from misuse," Grassley said in a press release May 16. "These organizations have a job to do and a public trust to keep," added ranking committee Democrat Max Baucus of Montana in the same press release. "If those obligations are being shirked, we're going to find out and put a stop to it," he said.

AHQA on Monday released a report on efforts by QIOs from 2002 through 2005 to narrow differences in quality of care received by racial and ethnic groups compared with care received by white Americans. QIOs typically targeted a specific underserved population and focused on improving performance on a specific quality measure for a specific condition. In 27 of 45 states, improvement efforts used by QIOs produced higher performance scores on quality measures than were shown in a national control group, according to the report.

In one example of QIO efforts to reduce disparities, a New York state QIO called IPRO sought to increase the percentage of black diabetics in the traditional fee-for-service side of Medicare who received blood tests at least once every two years to measure their risk of heart disease.

The campaign included tactics such as airing a total of 84 ads on radio stations with a significant black audience urging listeners to "talk to your doctor about your ABCs." The message referred to getting an A1C test, which monitors glucose levels in the blood, getting blood pressure checked, and getting cholesterol tested.

Other strategies to counter diabetes included meeting with community groups to show people the right proportions of foods to eat: half a plate of vegetables; one-quarter a plate of starches; and the remaining one quarter of meat. The right portion of meat was about the size of one's fist, beneficiaries were told.

The QIO also met with doctors in their offices to review the latest clinical guidelines for treating diabetes, provided chart stickers to remind doctors to order certain tests, and audited medical charts to provide feedback on treatments prescribed.

At Monday's briefing, IPRO's Terry Mahotiere said the project narrowed the difference between whites and blacks getting lipid profiles every two years by 11.9 percent. The percentage of black Medicare fee-for-service beneficiaries receiving the tests increased by 16.7 percent.

The report, which was prepared by QSource, the QIO for Tennessee, detailed other such programs with similarly "positive" results and called on Medicare to increase funding to QIOs to reduce disparities. Only 3.4 percent of QIO funding now goes for that purpose; Dawn Fitzgerald, the chief operating officer for QSource, said the figure ought to be more like 10 percent to 15 percent.

But Grassley and Baucus say QIOs need to spend more responsibly before their funding and responsibilities are increased.

In a May 18 letter, the senators posed follow-up questions to AHQA based on documents provided by the lobby to the Finance Committee in response to a January 25 request.

The letter asked for spreadsheets sought by AHQA from individual QIOs detailing executive salaries and an explanation for $13,907 in payments by AHQA to the Don CeSar Beach Resort Hotel in St. Pete Beach, Fla., for "events" on June 13 through June 16, 2005; "more than half of this amount was for lunches and banquets," the letter said.

On June 14 through 17, another QIO group, the Tri-Regional QIO Conference headquartered in Fort Smith, Ark., paid the same hotel $167,072 for events including the $123,00 in banquet charges and a pizza party, the letter said.

AHQA Vice President for Government Affairs Todd D. Ketch said the sum AHQA spent was largely for business dinners or lunches in which some 30 to 40 QIO medical directors discussed pending policy issues. Those meals and other business meetings were held concurrently with the Tri-Regional QIO conference, he said.

The remainder of the $13,907 was for audio/visual and telephone equipment used in conjunction with those meetings, said AHQA Executive Vice President David Schulke.

Ketch said the Tri-Regional group is separate from AHQA and referred a reporter to organizers of that conference to answer questions about their expenditures.

The senators' letter also asked the source of funding for "welcome receptions," "dinners," and "outings" at AHQA annual meetings dating back to 2002. Among them were a river trip, a Napa Valley winery dinner, and a "Murder Mystery Dinner." AHQA was asked to include "the amount of money, if any, charged to Medicare," and to list family, friends, and companions who attended each of the events listed.

Schulke said that billing the entire registration fee to Medicare for the meetings would be consistent with federal regulations but that some QIOs may have billed part of that fee to non-Medicare customers. Friends and family going on the outings had to pay their own way, he said.

Schulke added that detailed federal regulations allow QIO representatives to bill Medicare for receptions and dinners if the primary function of the overall meeting is educational. He said the meetings typically consisted of some 13 to 15 hours of education. QIO members had to pay their own way for the river outing.

Schulke added that in any event amounts billed for meetings are subject to annual audits carried out by contractors hired by the Medicare program. Disallowed amounts must be repaid, he said.

Ketch said AHQA would provide as much of the information requested "as we can." He added that "we want to be as cooperative as possible. AHQA will meet the June 16 deadline set by Grassley and Baucus for providing the data, Ketch said.

A representative of the Tri-Regional QIO Conference responded to a request for comment with an e-mail message saying that organizers "are not aware of what funds individual participants [QIOs] use for registration fees to attend the conference. The registration fee covers meals, space rental and equipment charges."

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