September 27, 2001 HHS Initiative on Rural Communities Department of Health and Human Services Hubert H. Humphrey Building 200 Independence Ave, SW Room 638 - G Washington, DC 20201 Re: Federal Register Volume 66, No. 168, Request for Comments to Inform HHS Initiative on Rural Communities Dear Secretary Thompson: I am writing on behalf of The American Health Quality Association (AHQA), the national association representing the nation's network of Medicare Peer Review Organizations (PROs), to urge your HHS Rural Task Force to build on the existing PRO contractor network to improve the quality of clinical care delivered in rural settings. This action would help satisfy the goals of your Initiative on Rural Communities as well as a portion of the President's framework for improving Medicare. Principle number eight of his framework calls for providing high quality care for all seniors and specifically states, "Medicare should address the additional challenges facing rural health care providers in delivering high quality care." HHS Should Capitalize on the Existing National Network of Peer Review Organizations (PROs) The PRO contracts are managed by the Office of Clinical Standards and Quality (OCSQ) in the Centers for Medicare and Medicaid Services (CMS). PROs are responsible for monitoring and helping to improve the clinical quality of care delivered to Medicare beneficiaries. They work with medical and administrative staff in nearly all Medicare participating hospitals in America, and in an increasing number of non-hospital settings, to improve systems of care. The main quality improvement priority of the PROs is the national Health Care Quality Improvement Program (HCQIP). Through projects in every state and territory, the PROs encourage the use of best practices for care delivered in six clinical areas: heart attack, congestive heart failure, pneumonia, stroke, diabetes and breast cancer. These illnesses affect a large number of senior citizens in both rural and urban areas. The PRO Program could do more to help rural communities, however. HHS should further invest in the PRO network and adequately fund them to reach out to even the most remote facilities in their states to help improve care. CMS currently evaluates each PRO's success in HCQIP based on their ability to show that care has improved on a statewide basis. While this method is appropriate from a broad public policy perspective, it encourages the PROs to work largely in high volume facilities where they can affect the most beneficiaries and move the statewide quality indicators upward. The incentives of this evaluation methodology discourage PROs from working in rural America. AHQA does not propose the elimination of this method of measurement because the PRO program, like any federally funded effort, must be accountable for optimum effectiveness. We recommend, instead, that CMS include a specific provision in the next round of PRO contracts that requires and adequately funds the PROs to address the needs of rural providers in their quality improvement efforts. This rural focus could be incorporated into HCQIP or another part of the PROs contract, but it will be necessary, in either case, for CMS recognize that working with more rural facilities will require additional expenses for staff, travel and technological assistance. AHQA and the PRO community expect additional expenses to be modest as they are only slightly modifying a well-established infrastructure with extensive experience. CMS could allocate the necessary funds in the next round of PRO contracts that begin next year. These contracts are funded by the Medicare Trust Fund and do not require approval through the Congressional appropriations process. For an incremental price, CMS can make Medicare's quality improvement efforts more equitable and show commitment to improving care administered to patients across America. Federal Panels Support High Standards of Care for Rural and Urban Areas through Expanded Rural Role for PROs Two well-respected federal organizations recently recognized that the quality of care in rural areas could be improved, just as it can in urban areas, but that appropriate resources and tools are necessary. They both recommend utilizing the PROs to provide the necessary technical assistance and expertise to improve care in rural facilities. The Medicare Payment Advisory Committee (MedPAC), in its June 2001 report to Congress, recommended that the PROs be directed and funded to perform their current quality improvement activities more extensively in rural areas. The National Advisory Committee on Rural Health, in its May 2001 report to Secretary Thompson, recognized that there are a limited number of measures currently in use, such as those used by the PROs, which are appropriate for rural areas. The Committee stated "..quality measures tend to address management of complicated problems in the high-volume environment, rural quality is often determined in the primary care ambulatory environment where problems that are common in the population are addressed. The Committee pointed to the PROs as the appropriate entities to "develop quality improvement tools that fit the rural environment with appropriate flexibility and an emphasis on outcome standards." PROs help facilities improvement in "processes" of care - a very feasible and appropriate approach to quality improvement in rural communities. Most of the indicators being used by the PROs in HCQIP concentrate on the care of common conditions that are medically relevant in both inpatient and outpatient settings in most rural areas. The data collection necessary for measuring these indicators is not burdensome. It does not require large sample sizes (which would require large patient populations) nor does it require state of the art data collection technology. In fact, PROs provide a choice of data collection tools to providers that are either electronic or paper based (see Attachment 1: National Health Quality Improvement Projects of Medicare PROs (1999-2002). PROs Help Small Rural Facilities Overcome Barriers to Quality Improvement Health professionals in rural facilities are dedicated to providing the best possible care, but often do not have the resources necessary to invest in clinical quality improvement efforts. Few, if any, full-time staff in these facilities are assigned to statistical analysis, epidemiology or quality improvement. Technical barriers also prevent these facilities from bringing about change on their own such as lack of access to technical equipment, journals, revised practice guidelines and direct interaction with specialty physician consultants. In February 2001, Dr. William Golden, past president of AHQA and Principal Clinical Coordinator of the Arkansas Foundation for Medical Care, Inc. (the Arkansas PRO), participated in an expert panel discussion on improving the quality of care in rural areas that was convened by the Medicare Payment Advisory Committee (MedPAC). His comments regarding the issue of identifying and overcoming barriers to improvement in rural areas is summarized below: "..There was lengthy discussion at the meeting regarding the barriers to quality improvement in rural areas including resource limitations, the need to use measures that are relevant, the need for greater technical assistance and the lack of advanced technology. All of these barriers are valid and problematic, but I believe it should be noted that the nation's network of Medicare Peer Review Organizations (PROs) is actively working around these problems or contributing to their solutions and bringing about improvement in rural areas. ".. The PROs are a model that uses appropriate process measures and provides hands on assistance to rural providers for implementing quality improvement strategies. This model will not be the silver bullet for quality improvement in all rural areas - but is an example of the kind of measurement and support that rural areas need to be on more of a level playing field with their urban counterparts. ".. Chart review is time consuming but necessary for benchmarking and rural practitioners do not have the time for this activity. This is an example of the PROs' usefulness as a "service model." The PRO staff is specifically trained to abstract medical records, analyze the data, create benchmarks and compare a facility's status to that of similar facilities. The PROs can also tailor data collection and improvement methods to the needs of a particular facility. This model is realistic and immediately useful for rural areas." Evidence of Improvement in Rural Facilities that Work with PROs The Iowa Foundation for Medical Care (the Iowa PRO) and the Oklahoma Foundation for Medical Quality, Inc. (the Oklahoma PRO) demonstrated improvement in rural facilities that worked with the PROs in the areas of heart attack and congestive heart failure. This data was cited in the June 2001 MedPAC report [see Attachment 2: Iowa Foundation for Medical Care, Data for Rural Hospitals - 5th Scope of Work Projects, Attachment 3: CCP Indicators Over Time and in Rural Versus Urban Oklahoma Hospitals and Attachment 4: Legends (for figures 1-4 of Attachment 3)]. Also attached is the abstract of a soon to be published report, "Improving the Quality of Care for Patients with Pneumonia in Small Hospitals." The Oklahoma PRO and several other members of academic institutions and health systems in Oklahoma and California conducted this study. The purpose of the study was to "demonstrate that a project implemented by a PRO in very small, predominantly rural hospitals would lead to an improvement in care that could not be accounted for by secular trends in the management of pneumonia." The results show marked improvement in care of pneumonia patients in these facilities after practitioners worked with the Oklahoma PRO to improve their processes of care and assure that patients received sputum cultures, blood cultures, and antibiotics in the right way at the right time (see Attachment 5: Improving the Quality of Care for Patients with Pneumonia in Small Hospitals). For additional information regarding these comments and the attached clinical information, please contact me or Sylvia Gaudette, Director of Government Affairs at 202-261-7569. Sincerely, David G. Schulke Executive Vice President cc: Stephen F. Jencks, MD, MPH David L. Thomas, MD