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IOM Report
Calls for QIO Program Expansion
USA Today
Editorial
Gingrich
Calls QIO Assistance a ‘No-Brainer’ for
Physician Practices
AHQA Releases
Proposal to Reform Beneficiary Complaint Process
New Checklist
Helps Home Health Care Providers Prepare For An Influenza Pandemic
Study
Shows All Adults at Risk of Poor Quality Care, QI Efforts Focusing
on Disparities May Miss the Mark
CCHIT: Paving
the Way for a New Era in HIT
Grassley
Inquires about AHA Efforts for Non-Profit Reform
Georgia
Quality Expert Tapped to Head AHA Quality Center
Low Chicago
Area Pneumonia Vaccination Rates
IOM Report Calls for QIO Program Expansion
In its recent
report, “Medicare’s Quality Improvement Organization
Program: Maximizing Potential,” the Institute of Medicine (IOM)
called for strengthening the QIO program through a “sharper focus
on technical assistance and more systematic and rigorous evaluations” and
making QIO services “available to all providers, Medicare Advantage
organizations, and prescription drug plans.” The QIO program “must
become an integral part of strategies for future performance measurement
and improvement in the health care system,” the nearly 300 page
report said.
The report
was released at a public briefing at IOM headquarters in Washington,
DC. Three members of the “Committee on Redesigning
Health Insurance Performance Measures, Payment, and Performance Improvement
Programs,” presented the report’s findings. Stephen Shortell,
PhD, Blue Cross of California Distinguished Professor of Health Policy
and Management and Dean, School of Public Health, University of California
Berkeley, led the discussion, accompanied by committee members Gail Wilensky,
PhD, Senior Fellow, Project HOPE, and Robert Galvin, MD, Director, Global
Health Care, General Electric Company.
The report
on the QIO program is the second in a series designed to offer IOM
recommendations to improve the American health care system. A previous
report discussed ways to measure and report on health care providers’ performance,
and a third report will examine payment incentives to improve the quality
of health services.
The QIO report’s emphasis on technical assistance is by design
said Galvin, “this is just one leg of a three-legged stool” that
aims to improve health care quality. “The importance of providing
technical assistance in the future will be so important in coming pay
for performance efforts,” said Wilensky. “You can’t
change payment without measures and you can’t expect providers
to change without technical assistance,” she continued.
“This report is a strong endorsement of the value of the QIO program
and its core work of quality improvement technical assistance,” said
David Schulke, AHQA EVP. AHQA is in agreement with most of the IOM’s
recommendations, including those calling for broader-based QIO governance,
expansion of technical assistance, more competition, better management
by CMS, more timely data processing, rigorous evaluation and scrutiny
of the program, and increased funding for the core contract. The report
also calls for CMS to ease conflict of interest restrictions to allow
QIOs to “serve more providers and beneficiaries” by securing
non-CMS funds.
In its recommendations,
the IOM also called for narrowing the scope of the core QIO contracts
by regionalizing or nationalizing responsibility for handling beneficiary
complaints and appeals and other case review functions. The IOM suggested
that a handful of organizations could be contracted to do this work
nationwide and noted that QIOs should be able to bid on these contracts.
When questioned by AHQA EVP David Schulke on this issue, IOM panel
member Wilensky said that the committee felt there was a “fundamental conflict” between quality improvement
and “regulatory” activities. Discussion leader Shortell offered
further clarification that the IOM was not “suggesting a disconnect
between review and quality improvement” because a method of integration
should be developed.
Last week
AHQA formally released and distributed to Congress and the media and
stakeholder organizations a set of legislative proposals for comprehensive
reform of the beneficiary complaint program that would address many
of the IOM’s concerns about responsiveness and transparency
for patients. Read AHQA’s recommendations at www.ahqa.org.
The IOM
report also calls on QIOs to make their boards more diverse and accountable
to the public. AHQA supports this recommendation, noting that 33 of
the Association’s 40 Institutional Members (responsible
for QIO work in 44 states) have already signed on to a new code of conduct
developed late last year that sets high standards for board and executive
compensation, diversity, travel expenses, and conflict of interest (read
the new policy at www.ahqa.org).
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CMS Management
The
IOM took the Centers for Medicare & Medicaid Services (CMS)
to task for what it calls “absence of overall strategic priorities,
a comprehensive evaluation plan, and program guidance” as well
as an “excessive level of process management of the QIOs.” The
report makes numerous recommendations to improve CMS management of the
program for the upcoming 9th Scope of Work, including:
• Setting clear program goals and priorities
• Increased QIO competition
• Less process management of internal QIO operations
• Awarding of QIOSC contacts prior to the QIO contract cycle so tools
and materials are available at the beginning of the contract
• Increased knowledge sharing activity
• Improved coordination and communications between the agency and
QIOs
• Consistent performance periods
QIO Effectiveness
While
recognizing that the quality of “health care received by
Medicare beneficiaries has improved over time,” the IOM said it
could not conclusively document the impact of “individual QIOs
or the program as a whole.” The lack of evidence, the report said,
does not mean that QIOs have no impact. Rather, it illustrates that difficulty
in measuring effect is a distinct characteristic of quality improvement
interventions in general -- whether undertaken by QIOs or other organizations.
The same
issue was raised in previous reports on the QIO program, the IOM said.
New recommendations encourage CMS to “develop four types
of evaluation” to accurately assess the program. The panel called
for evaluations of 1) the program as a whole, 2) individual QIO performance,
3) select interventions, and 4) periodically commissioned independent,
external evaluations.
Schulke
commented, “On
the merits, this is a sound suggestion. In terms of equity, however,
the QIO program is being held to a standard that government programs
are seldom asked to meet. AHQA had previously submitted to IOM a number
of studies documenting the effectiveness of QIO interventions. But
there are only six well designed studies with a comparison group, and
fewer still with anything like randomization of participants. IOM cited
most of them, but apparently thought these covered too few states to
stand for the national program. The answer to this is a simple, well
thought out evaluation, constructed by experts in evaluation who are
aware of the practical issues in imposing research design on clinical
improvement work.”
CMS Response
Calling
the IOM report a “central point in the national conversation” about
improving the health care system, Barry Straube, MD, Acting CMS Chief
Medical Officer and Director of OCSQ, said in a statement, “In
short, the QIO program is doing important work and we are pleased that
the IOM recognizes that QIOs are “a potentially valuable nationwide
infrastructure dedicated to promoting quality health care.””
Read the IOM report at: http://www.iom.edu/CMS/3809/19805/33411.aspx
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USA Today Editorial
With a focus
on the handling of beneficiary complaints, an editorial in today’s
issue of USA Today strongly criticizes the QIO program, and questions
whether taxpayer funds for the program are being wisely spent. Despite
briefings by AHQA staff earlier this week, the editorial contains a
number of inaccuracies about the program.
In a rebuttal,
CMS Administrator Mark McClellan, MD, PhD, wrote in USA Today that
the QIO program is “an important element” in the
agency’s efforts to improve care. “But we agree that the
program can be even better, and we have already taken steps to get more
bang for the buck,” McClellan continues. The Administrator explains
that many of the changes needed to revamp the program are not in the
agency’s hands but require Congressional action.
AHQA immediately submitted a letter to the editor of USA Today this
morning that corrects inaccuracies in the editorial. AHQA staff will
also be working to make sure that policymakers are aware of misperceptions
that may be created by the editorial.
Read the editorials: http://www.usatoday.com/news/opinion/front.htm
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Gingrich
Calls QIO Assistance a ‘No-Brainer’ for Physician
Practices
In testimony before the House Government Reform Subcommittee on the
Federal Workforce and Agency Organization on Wednesday, Former Speaker
of the House and founder of the Center for Healthcare Transformation
Newt Gingrich discussed the value of QIO assistance to help physicians
adopt HIT.
Gingrich
said, “From readiness assessments and cost analyses to
guidance on advanced functionality and workflow redesign, physicians
can utilize their expertise and experience—at no charge. It is
a “no-brainer” for physician practices across the country
to tap into this valuable resource.”
The inclusion
in Gingrich’s testimony is the result of AHQA’s
efforts to reach out to Mr. Gingrich and his organization over the past
several months to share the great work QIOs are doing in the field. “We
are so pleased that Mr. Gingrich shared his support for the QIO HIT work
with Congress today, as he has in other recent public forums. He is an
exceptional leader in this field, and we are grateful for his efforts
to raise awareness of the value of QIOs,” said Christine Bechtel,
AHQA Director of Government Affairs.
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AHQA Releases Proposal to Reform Beneficiary Complaint Process
In response to long-standing concerns about the lack of transparency
in the current Medicare beneficiary complaint process, AHQA recently
released new recommendations to Congress that call for major reforms,
including revising current Medicare law and regulations that prohibit
beneficiaries from knowing the results of QIO investigations.
The proposal for a Medicare Quality Accountability Program (MQAP) was
approved by the AHQA board in late February and is the second in a series
of recent AHQA proposals to modernize the QIO program. (The first in
the series, Standards for Organizational Integrity of AHQA Institutional
Members, was released in late December and has been adopted by three-quarters
of QIOs nationwide.) The new MQAP proposal would require:
- Beneficiaries
or their representatives to receive information from the QIO
about the findings of their complaint and actions taken to prevent
the problem from recurring. QIO findings would be inadmissible as
evidence in malpractice suits.
- QIOs
to help good providers improve systems of care
- QIOs
to educate beneficiaries about their right to complain and train
providers to welcome and resolve patient concerns.
- QIOs
to refer providers unwilling or unable to improve to the appropriate
authorities.
- QIOs
to produce annual quality reports in each state, including aggregate
data on complaints, provider performance on standardized quality
measures, and names of providers that have been referred for enforcement
action
“This approach strikes a proper balance,” said David Schulke,
AHQA Executive Vice President. “Medicare must investigate consumer
concerns and report confirmed findings whether the complaint involves
an institution or a physician. Medicare also has an interest in seeing
that confirmed problems are corrected swiftly and effectively, so QIO
assistance and follow up monitoring is essential.”
AHQA proposes that the recommendations be written into the Social Security
Act to replace the existing beneficiary complaint program paragraph at
Section 1154(a)(14), while other provisions, such as EMTALA review and
expedited appeals, would remain in place.
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New Checklist Helps Home Health Care Providers Prepare For An Influenza
Pandemic
The Department of Health and Human Services (HHS) released a newly developed
checklist to help home health providers assess their readiness to respond
in the event of an influenza pandemic. HHS released the document at a
recent Pandemic Planning Summit in South Carolina. Similar summits are
being held in conjunction with state and local officials in every state
over the next few months.
“Home health care providers will provide critical services during
an influenza pandemic,” Secretary Mike Leavitt said. “Their
ability to care for people at home and help reduce stresses on overburdened
hospitals will be a key element in effectively dealing with a pandemic.
Identifying strengths and weaknesses in their organizations now and building
community contacts in advance will provide a strategic advantage if a
pandemic influenza strikes.”
While the
checklist was designed as a response to a pandemic influenza, it could
be helpful in other types of emergencies. Suggestions include:
- Creating
a planning committee to specifically address pandemic influenza
preparedness;
- Identifying
points of contact at local and state health departments, emergency
management service providers, and other health care providers in
the community;
- Ensuring
your plan complements local response plans;
- Planning
for an increase in patients who require home health care services
during a pandemic;
- Planning
for an increased demand on supplies, such as masks, hand hygiene
materials, food, medications and other necessities;
- Developing
a system for evaluating symptomatic personnel before they report
for duty;
- Identifying
the minimum number and categories for nursing staff and other professional
personnel necessary to sustain home care services for a given number
of patients;
- Developing
a contingency staffing plan.
This effort
is one of many the administration is undertaking as part of what it
says is a coordinated government strategy to increase pandemic preparedness.
A copy of the “Home Health Care Services Pandemic
Influenza Planning Checklist,” along with other checklists and
pandemic planning information is available at www.pandemicflu.gov.
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Study Shows All Adults at Risk of Poor Quality Care, QI Efforts Focusing
on Disparities May Miss the Mark
In a New
England Journal of Medicine article published March 15, investigators
find that differences in the quality of care received by various socio-demographic
subgroups pales in comparison to the large gap between recommended care
and the care actually provided. Accordingly, the authors conclude, “Quality-improvement
programs that focus solely on reducing disparities among socio-demographic
subgroups may miss larger opportunities to improve care.”
The study, “Who Is at Greatest Risk for Receiving Poor-Quality
Health Care?” shows adults receive only 54.9% of recommended care,
putting everyone over age 18 – regardless of socio-demographic
factors -- at risk for receiving poor quality health care. The authors
used data from medical records and patient interviews from a random sample
of adults living in 12 communities who visited a health care provider
at least once in the previous two years. The data was compared to quality
indicators for 30 chronic and acute conditions and disease prevention.
Other findings include:
- Women
received a higher proportion of recommended care than men (56.6%
vs. 52.3%).
- Quality-of-care
scores declined with age (57.5% 18 through 30 vs. 52.1% 65 years
and up).
- Annual
family incomes over $50,000 increased quality-of-care scores by 3.5
percentage points over incomes of less than $15,000.
- Overall
quality-of-care was 3.5 percentage points higher for blacks than
for whites and 3.4 percentage points higher for Hispanics than for
whites.
- Compared
to those without health insurance, Medicare beneficiaries were more
likely to receive good quality care by 3.2 percentage points.
- Women
had higher scores than men for preventive care (57.8% vs. 50.1%)
and chronic care (57.9% vs. 54.5%) but lower scores for acute care
(51.9% vs. 58.4%).
- Adults
under 31 were significantly more likely to receive preventive services
than those 31 through 64 years of age (difference, 3.8 percentage
points) or those 65 years of age or older (difference, 8.8 percentage
points).
- Participants
31 through 64 years of age received significantly better chronic
care than those under 31 years of age (57.3% vs. 50.9%).
- Blacks
had higher scores for chronic care than did whites (61.3% vs. 55.4%).
- Annual
family incomes of at least $15,000 led to significantly higher scores
for preventive care than those with lower incomes.
- Women
had higher scores than men for screening (56.7% vs. 42.9%) but lower
scores for treatment (56.0% vs. 59.3%).
- Younger
and wealthier participants also had higher scores for screening,
but younger participants had lower scores for follow-up than older
participants.
- Blacks
had higher treatment scores than whites (64.0% vs. 56.3%) and Hispanics
had higher screening scores than whites (55.9% vs. 51.6%).
- The principal
advantages for Medicare beneficiaries were in diagnosis and treatment.
This article
is available for free at: http://content.nejm.org/cgi/content/full/354/11/1147
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CCHIT: Paving the Way for a New Era in HIT
Less than two years after a federal government report called for the
certification of health information technology (HIT) products, the Certification
Commission for Healthcare Information Technology (CCHITSM) is in the
final stages of preparation to launch commercial certification. CCHIT
implemented an ambulatory electronic health record (EHR) pilot test of
six vendors in January and February of this year. Through March 31, the
public is being given the chance to weigh in on the details of the proposed
plan by visiting www.cchit.org. The first certified vendors are expected
to be announced in late June.
The initiative began with the release of The Decade of Health Information
Technology: Delivering Consumer-centric and Information-rich Health Care,
a report issued in July 2004 by David J. Brailer, MD, PhD, the National
Coordinator for Health Information Technology. The report listed twelve
strategies for improving health care, including the certification of
HIT products.
The certification challenge was undertaken by the American Health Information
Management Association (AHIMA), the Health Information and Management
Systems Society (HIMSS), and The National Alliance for Health Information
Technology (Alliance), which jointly launched CCHIT as a voluntary, private-sector
initiative to certify HIT products. In addition to support from these
three associations, funding was provided by the American Academy of Family
Physicians (AAFP), the American Academy of Pediatrics (AAP), the American
College of Physicians (ACP), the California HealthCare Foundation (CHCF),
Hospital Corporation of America, McKesson, Sutter Health, United Health
Foundation, and WellPoint Health Networks, Inc.
In September 2005 CCHIT received a three-year, $7.5 million contract
from the U.S. Department of Health and Human Services (HHS) to develop
and evaluate certification criteria and an inspection process for EHRs
in three areas: certification of ambulatory EHR products; developing,
testing, and certification of EHR products for inpatient care settings;
and certification of the infrastructure or network components through
which EHRs operate.
CCHIT’s
mission is to accelerate the adoption of HIT by creating an efficient,
credible, sustainable mechanism for certification of EHRs, with the
following goals:
- Reduce
the risk of HIT investment by providers
- Ensure
interoperability of HIT products with emerging health information
infrastructures
- Enhance
the availability of HIT adoption incentives from public and private
purchasers/payers
- Protect
the privacy of patients’ personal
health information
CCHIT is governed by a 19-member Board of Commissioners of diverse stakeholders
and is chaired by HHS Secretary Mark Leavitt, MD, PhD. Volunteer work
groups, which are charged with developing the criteria and inspection
process that will be used to certify products, include: ambulatory functionality,
inpatient functionality, interoperability, security, and certification
process. The work groups have already addressed specific concerns that
arose during the pilot test period. The CCHIT will review the comments,
finalize the products and announce the first certified vendors in late
June.
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Grassley Inquires about AHA Efforts for Non-Profit Reform
Senator
Charles Grassley (R-IA) Chairman of the Senate Finance Committee recently
sent a letter the American Hospital Association president, Richard
J. Davidson, discussing the association’s efforts to advise its
non-profit membership on reforms in accordance with suggestions the Senator
made in an October 24, 2005 speech to The Independent Sector.
While recognizing
AHA’s recent efforts to propose non-profit hospital
reforms that would address his concerns, the Senator suggests that the
AHA “can and should take a more active and serious role in this
discussion.” The Senator is seeking to understand if AHA properly
advised its non-profit hospitals on HHS guidance or if select hospitals
ignored such efforts. In addition, the letter requests information related
to AHA’s governance structure and board member selection process.
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Georgia Quality Expert Tapped to Head AHA Quality Center
The American Hospital Association (AHA) named Georgia health care quality
expert Stephen Mayfield to head the AHA Quality Center, a new resource
that will be available to the hospital field this spring. Mayfield officially
joined the AHA on March 1 as senior vice president, quality and performance
improvement, and director, AHA Quality Center.
Last year, the AHA Board of Trustees approved the creation of the Quality
Center as a resource designed to help hospitals accelerate their quality
improvement processes to achieve better outcomes and improve organizational
performance. In collaboration with leading quality improvement stakeholders,
it will bring together knowledge, expertise, and demonstrated methods
in quality and patient safety from across the hospital field.
Mayfield, who comes to AHA from Athens Regional Medical Center in Athens,
Ga. has directed the quality and patient safety programs at several hospitals
and health systems.
Low Chicago
Area Pneumonia Vaccination Rates
In a recent
articles in the Chicago Sun-Times, Dale Bratzler, DO, MPH, coordinator
of Medicare’s
National Pneumonia Project and Principle Clinical Coordinator at
Oklahoma Foundation for Medical Care, the Oklahoma QIO, discusses the
importance of pneumonia immunization and how publicly reported data
on Hospital Compare has helped spur hospitals to immunize elderly and
at-risk patients.
In addition
to publishing basic facts about pneumonia, Sun-Times, analyzed three
pneumonia measures on the Hospital Compare site and contacted Chicago-area
hospitals with low scores. Most hospitals responded that the data on
the federal website is dated and does not reflect current efforts.
Many of the hospitals said that after implementing system changes such
as standing orders, their rates have gone up. But some remain well
below the national average. “We
don’t expect any hospital to get
to 100 percent on these measures,” Bratzler told the paper, “But
if hospitals are below the national average, that’s harder
to explain.”
Bratzler
also told the paper that having to publicly report rates on Hospital
Compare has prodded many hospitals to make changes. “Pressure
to post higher percentages is bound to increase in the near future
as Medicare and others move toward pay-for-performance, where a
hospital’s
reimbursement is linked to how well it follows various measures,” the
article notes.
Read the
article at: http://www.suntimes.com/output/news/cst-nws-pneum06.html
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