Recommendations Would Benefit Consumers, Physicians, Providers

Washington , D.C. – The American Health Quality Association today released a policy proposal calling for major reforms of a program directed by the Centers for Medicare and Medicaid Services (CMS) that investigates complaints by Medicare beneficiaries about quality of care.

CMS contracts with Quality Improvement Organizations (QIOs) in each state to investigate complaints but prohibits QIOs from telling beneficiaries the details of investigations involving physicians without permission from those physicians. Without permission, QIOs can only tell complainants whether the complaint was confirmed; they cannot reveal what went wrong or why.

AHQA, which represents the national network of QIOs, proposes that QIOs inform beneficiaries of findings, launch a national campaign to promote more timely and direct patient feedback to providers, and help providers correct confirmed problems reported by consumers.

AHQA: Tell Beneficiaries What Happened

AHQA is proposing that the findings of QIO investigations of complaints be given to Medicare beneficiaries who file complaints, along with information about actions taken to prevent the problem from recurring. The proposal would make QIO findings in complaint investigations inadmissible as evidence in malpractice suits.

“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.”

Schulke emphasized “It isn’t just Medicare that must appreciate that consumer concerns are important indicators of quality breakdowns. Providers too must learn to actively welcome consumer concerns, and take timely action to improve care so there is no need to bring in the QIO. If problems can’t be worked out, then the QIO can be called in. The QIO’s objective must be a just outcome. By that we mean three things: lasting quality improvement occurs, good people are not blamed for system failures, and incompetent or reckless people are punished.”

AHQA: Educate Beneficiaries and Engage Providers in Improvement Efforts

AHQA proposes a “Medicare Quality Accountability Program” that would:

• Assign QIOs to offer training to all providers, to teach them best practices for welcoming feedback about care problems and promptly resolving them.
• Restore active QIO outreach to educate beneficiaries of their right to bring quality concerns to QIOs -- and their responsibility to directly inform providers of their concerns.
• Respond supportively to quality problems arising because good people are working in unsafe circumstances, and punitively to those arising from incompetence or recklessness.
• Assist providers in remedying problems reported by patients and confirmed by QIOs.
• Refer to enforcement authorities providers that are unwilling or unable to improve.
• Clarify that QIOs must report findings of investigations of physicians to complainants, as CMS has instructed QIOs to do with findings relating to institutional providers.
• Prohibit use of QIO complaint inquiry findings in any form in a malpractice case.
• Instruct QIOs to publish annual quality reports in each state, including aggregate data on complaints, provider performance on standardized quality measures, and names of providers which have been referred by the QIO for enforcement action.

New Policy Part of Modernizing QIO Program

AHQA’s call to reform the beneficiary complaint program was approved by the Association’s board of directors in late February. It follows AHQA’s adoption late last year of a new policy to assure that all QIOs conform to the highest standards for business practices, governance, and public accountability. The new code of conduct—formally adopted by over two-thirds of QIOs—set standards for board and executive compensation, diversity, travel expenses, and conflict of interest.

To implement AHQA’s proposals for reform of the beneficiary complaint process, Congress will need to revise the law governing operation of the QIO program. Responding to beneficiary complaints is a small part of current QIO initiatives, which focus mainly on proactive efforts to improve care by providing technical assistance to hospitals, physicians, nursing homes and home health agencies. Congress will examine how to modernize the QIO program after receiving a report on the program from the Institute of Medicine . The IOM report is expected this week.

The American Health Quality Association is dedicated to improving the safety and effectiveness of health care. AHQA represents the national network of Quality Improvement Organizations (QIOs) that work with hospitals, medical practices, health plans, long-term care facilities, home health agencies, and employers to encourage the spread of best clinical practices and improve systems of care delivery.