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Medicare Quality Improvement Stagnating, Senators Complain

By John Reichard, CQ HealthBeat Editor

August 7, 2007 – Max Baucus, D-Mont., was soothing in his assessment while Charles E. Grassley, R-Iowa, was gruff, but the Senate Finance Committee leaders agreed on one thing in the marks they handed out last week to Medicare's Quality Improvement Organizations: "QIOs" need to be shaken up to live up to their names. A bill they introduced last week aims to do that by prescribing a heavy dose of competition and splitting up their functions to improve QIO performance.

QIOs, which work with doctors, hospitals, nursing homes, and others to improve the quality of care they deliver to Medicare patients, say the added competition is okay. But the overhaul of QIOs under the bill is overkill, they contend.

QIOs enjoyed a solid reputation in the health policy community for many years for their work to improve the quality of care. Each renewal of the three-year contract the organizations sign with Medicare contained added responsibilities to improve the quality of treatment received by Medicare beneficiaries.

But Grassley said in remarks on the Senate floor Aug. 2 that an investigation he launched two years ago of QIOs "revealed a program in desperate need of reform. This program was running with little or no oversight, and it was expending more than one billion dollars every three years with little measurable results." He added "one QIO leased residential properties for board members and a CEO. That same QIO also used federal funds to lease automobiles for its top executives. I also found that other QIOs who had board members and staff attend conferences, many at lavish resorts."

Grassley also said that while QIOs investigate complaints of poor quality care, they often do not share the findings with those who file the complaints. In one case, the husband of a nursing home patient who died filed a complaint about the care she received, but had to take legal action to learn the findings of the QIO investigation, Grassley said.

The bill (S 1947) introduced by the pair would strip out the complaint investigation role of QIOs and give it to new organizations called Medicare Provider Review Organizations (MPROs). The new entities would be required to report on the findings of their investigations to those who file complaints. QIOs would have to provide technical assistance in improving quality to facilities "that need help the most," the senators said.

Grassley pointed to June 29 findings by the Government Accountability Office that QIOs that work intensively with nursing homes to reduce cases of bed sores or lessen the use of physical restraints to keep residents from wandering do not target their assistance to facilities with the most quality of care problems.

"Most QIOs' primary consideration in selecting homes was their commitment to working with the QIO," the GAO analysis found. Problems with measures used to assess quality make it hard to evaluate the performance of QIOs, GAO added. However, it reported that "staff at most of the nursing homes GAO contacted attributed some improvements in the quality of resident care to their work with the QIOs."

Baucus said QIOs have done good work and provided valuable services but need a sharper focus. "It seems there is a consensus that the QIO program could be doing more to help improve the quality of care," he said.

Under the bill, priority would be given to helping providers in rural or underserved areas, those in financial need, those that perform poorly on quality measures and those that have many beneficiary complaints. The bill would allow other types of organizations to compete with existing QIOs to perform their services and eliminate the renewal of contracts that are not competitive. QIOs would be evaluated on consistent measures allowing their performance to be compared. Good performers would get financial rewards while poor performers would receive financial penalties.

The American Health Quality Association, which represents 42 QIOs nationwide, said it is seeking "middle ground" on the measure. "It's both costly and unnecessary" to create MPROs, said David Schulke, the association's executive vice president. Beneficiaries should receive the results of complaint investigations but all that's needed to make that happen is a change in regulations, he said. The bill also lacks sufficient safeguards to keep Medicare dollars from going to projects unrelated to the QIO program, he said.

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