Title: `Gotcha' gives way to guidance: Quality improvement behind plan to change Medicare review groups' image Published: 12/17/2001 By: Ed Lovern Section: Week in Healthcare The Bush administration wants to reshape the image of the state-based private organizations that oversee Medicare providers' quality of care from snapping watchdogs to trusty guide dogs. A draft workplan released earlier this month would move quality-improvement organizations, formerly called peer-review organizations, from ``the regulatory `gotcha' approach to more of a quality-improvement assistance approach,'' Jeffrey Kang, M.D., the Centers for Medicare and Medicaid Services' chief clinical officer, told Medicare's Participating Physicians Advisory Council last week. QIOs say the focus on quality improvement isn't new for them but confirm that the proposed three-year workplan, called the Seventh Contract Cycle Statement of Work, is a significant change. ``It is ambitious, it is innovative, and it is very demanding,'' said David Schulke, executive vice president of the American Health Quality Association, a trade association that represents QIOs. QIOs, which previously devoted most of their attention to hospital and physician quality issues, would also be charged with improving the quality of care for nursing homes and home healthcare providers (Nov. 19, p. 8). The new workplan, commonly called the ``seventh scope of work,'' becomes effective in September 2002. The CMS is accepting comments on the draft until Dec. 19. ``It is going to be a learning experience for all of us,'' said one state QIO chief executive who requested anonymity. Nursing home quality measures, produced from clinical data already collected by the CMS, would be published on consumer-accessible Web sites for providers across the country as soon as fall 2002. Home health providers would also have their quality statistics made public during the seventh workplan, which runs from September 2002 to September 2005. The CMS also wants to publish quality measures for individual hospitals but has no system in place for collecting such information. ``Maybe in two or three years we could be in a position to publish either voluntary or mandatory reported performance measures'' for hospitals, Kang said. Publicly available quality data for physicians are even further away because of difficulties defining episodes of care, Kang said. The QIOs' bigger workload is likely to come without a corresponding increase in pay. The CMS pays the 38 QIOs serving every U.S. state and territory a total of about $300 million a year. The CMS has requested new funding for the next contract cycle from the Office of Management and Budget. ``They have asked for less than 10% more (money) than they had in the sixth scope (of work) and there is way more than 10% effort in here. We're not sure it matches up,'' Schulke said. The OMB is expected to set the pay for the QIO program this month. The latest workplan would also give QIOs new accountability in improving rural healthcare, educating the public about how to use quality data, and handling beneficiary complaints against providers. The expanding demand to assist providers with quality improvement and the limited budget may push QIOs further from their traditional role of reviewing medical cases to monitor the performance of individual providers, said one QIO official. ``I do probably expect it to decline,'' said John Wiesendanger, chief executive officer of the West Virginia Medical Institute, the QIO serving that state, when asked if he would devote fewer resources to case review activities under the new guidelines. However, Kang assured worried physicians on the advisory council last week that changes proposed in the workplan draft, which include the requirement that QIOs add more consumers to their governing boards, would not weaken the confidentiality of the peer-review process. The CMS is also seeking to scale back the QIOs' role in monitoring and reducing Medicare payment mistakes to providers, called the Payment Error Prevention Program. But, on the whole, more would be added to QIOs' responsibilities than taken away. The proposal to enhance the beneficiary complaint program run by QIOs comes just four months after the HHS inspector general's office released a critical report of how QIOs respond to complaints about Medicare providers. The new workplan would add a mediation option to the complaint program. Most beneficiary complaints against Medicare providers aren't due to bad clinical care, but instead are the result of inadequate communication between the patient and the physician, Kang said. A complaint mediation process should provide beneficiaries with ``a little more satisfaction,'' Kang said.