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QIOs Expand Services to Address Quality of Care Complaints
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October
10, 2003
For Immediate Release |
Contact:
Richard Deutsch
202-331-5790 Ext. 313 |
Washington,
D.C.—Quality
Improvement Organizations (QIOs)
across the nation are offering
a range of new services to more
quickly and effectively resolve
complaints by Medicare beneficiaries
about poor quality of care. These
include assigning case managers
to track the status of cases
under review, using beneficiary
satisfaction
surveys to drive continuous improvement
of the complaint response process,
and offering beneficiaries the
option of mediation to resolve
concerns about care.
Under
contract to the Centers for
Medicare and
Medicaid Services
(CMS) at HHS, QIOs are responsible
for responding to written complaints
by Medicare beneficiaries about
unsatisfactory care. QIOs use
a “peer
review” process to respond,
which involves assigning medical
professionals to review cases
confidentially with providers
named in the complaint.
The Office of the Inspector General
at HHS issued a report in 2001
citing major flaws in the beneficiary
complaint program and charging
that the peer review process
often failed to provide a meaningful
response to complainants. The
new
QIO services being introduced
are intended to make the process
more
customer-driven and effective.
“QIOs
are pleased that CMS has taken
these steps to improve
the beneficiary
complaint process,” said
David Schulke, executive
vice president of the American
Health
Quality
Association, which represents
QIOs nationwide. “The
process should be patient-centered.
QIOs
are ready to quickly move
in that direction.”
Beneficiaries
who file complaints should
find it easier to
keep track of their cases because
QIOs are
now assigning case managers
to serve as a single, constant
point
of contact for all activities
related to each case. Following
completion
of reviews, QIOs are asking
beneficiaries to formally
evaluate
the
services they received.
These beneficiary satisfaction
surveys are being
used as guides to improving
the complaint response
process.
Perhaps
the most significant innovation,
however, involves the use
of mediation to resolve
many complaints.
The Mediation Option
Investigation of the complaint process shows that approximately four out
of five beneficiary complaints filed with QIOs have been found to be the
result of misunderstandings, lack of communication, or the patient’s
perception of treatment. Mediation offers beneficiaries, providers, and
physicians the opportunity to discuss such misunderstandings and disagreements
in a safe, confidential environment. Participation in mediation is voluntary
and offered free of charge by QIOs to all parties.
Mediation is not designed to assign blame or to determine
which party is right. Its goal is to foster communication leading to mutual
understanding of perspectives and agreement not to further pursue the
dispute. Nothing that is said in mediation can be used in legal proceedings.
Studies have shown that mediation is particularly useful in heading off
costly malpractice suits over disputes that could be resolved through
discussion.
“QIOs will continue to investigate care that is
clearly unacceptable and refer such cases to authorities who can take
disciplinary action. That’s not going to change,” said Schulke.
“Mediation is an added service that generally works more quickly
than traditional case review. It promotes communication. Often that’s
mainly what patients want—to feel accepted as a partner in the process,
not just another patient to be treated.”
When a beneficiary files a complaint, QIO staff will review
the case to see if care failed to meet professionally recognized standards.
If so, the QIO will thoroughly review the case, then recommend and monitor
a corrective action plan. If not, both the beneficiary and the provider
will be offered mediation in a session facilitated by a professional,
impartial mediator. If either party declines, the case can be subsequently
referred to traditional case review.
The use of mediation to settle beneficiary complaints
has been pilot tested by QIOs in six states, with most beneficiaries and
providers expressing satisfaction with the process and the outcome. In
many cases that went through mediation, beneficiaries received acceptable
explanations for their physician’s treatment and assurances that
steps will be taken to address the concerns identified in the complaint.
QIOs are also prepared to use mediation agreements, when appropriate,
to launch targeted quality improvement projects that address failure or
breakdown of systems of care that resulted in the complaint.
More on Quality Improvement
Organizations: www.ahqa.org
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