AHQA comments to CMs on delivery schedule requirements under the Seventh Scope of Work

January 7, 2003 Ed Hughes Contracting Officer Acquisitions and Grants Group Centers for Medicare and Medicaid Services C2-21-15 7500 Security Boulevard Baltimore, Maryland 21202 Dear Mr. Hughes: We are writing on behalf of the Medicare Quality Improvement Organization (QIO) contractors to detail concerns regarding certain delivery schedule requirements under the Seventh Scope of Work (SOW7). Delays in various products and information from the Centers for Medicare and Medicaid Services (CMS) and its QIO Support Contractors (QIOSCs) have already caused considerable confusion as the QIOs plan their work and hire and direct staff. Ultimately, these delays could lead to compromised contract performance, competitive disadvantages and escalated costs despite the QIOs’ best efforts to fulfill their contractual obligations. We believe these delays are likely to adversely influence CMS evaluations of QIOs, subjecting them to competitive renewal and reduced award fee. In addition, certain of these failures to produce timely deliverables may adversely affect long-term provider and practitioner perceptions of the dependability and reliability of QIO contractors, beyond the Seventh Scope of Work. These adverse perceptions may well compromise the QIOs’ ability to recruit providers and persuade them to invest the resources needed to achieve measurable improvement in the quality of health care. Although the QIO contract purports to hold the QIOs harmless for performance problems and delays of certain subcontractors and lead QIOs, it is unclear to what extent CMS intends to make similar allowances for its own delays. It is also questionable whether adjustments will be made in the evaluation process to recognize sufficiently the impact of other parties’ shortcomings on the QIO’s performance. There may be differences in the effects of these problems on individual QIOs, and contracting rounds of QIOs, but all QIOs are at risk of being held responsible for delays and decisions that were beyond their control. This letter necessarily consists of a list of problems that require CMS attention. But the point of the letter is not to establish blame. Rather, we are requesting that you consider each problem area identified below and work with the AHQA elected leadership and staff to determine how to avoid unreasonable fee reductions and risk of competitive renewal, despite QIOs best efforts. CMS Abstraction and Reporting Tool (CART) The continued problems with the availability and functionality of CART affect the contract performance of all QIOs. All QIOs are being held responsible for getting at least 50% of the hospitals in every state to self-report data into the national repository. CMS is not allowing QIOs to discuss any abstraction tools with hospitals other than CART, which was due in an operating form to the QIOs on August 1, 2002. This tool was delivered two and a half months late. Beta Version 1.0 was released on August 1, 2002 but was found to be uninstallable. Beta Version 1.1 was released on August 9, 2002 but it could not be opened due to lack of instructions on how to set up a user. Installation and user instructions were released on August 14, 2002. Production Version 1.2 was released on October 16, 2002, but had significant functional difficulties. Some of them have now been addressed but others continue to compromise its usability. The Web based version was supposed to be available in November 2002 but will not be released until March 2003. QIOs in states with a large number of JCAHO-accredited hospitals have to rely on various "Oryx" vendors [or what are now called Performance Measurement System (PMS) vendors] in that state to agree to submit data to CMS because hospitals are using vendors to prepare data for submission. In addition to the delay in delivering CART to the QIOs, CMS was late in delivering the specifications to the vendors who initially agreed to incorporate CMS elements into their abstraction tools. In most cases, this will delay the ability of those vendors to include CART elements in their proprietary tools until next year. The only control QIOs have in this whole situation is "damage control." The delay of CART and its continued glitches are eroding the QIOs’ progress with hospitals and their vendors. The delay could force some QIOs to enter several months of data into CART that was collected by using paper tools, raising costs. Even worse, it could cause some hospitals and vendors to decide they can no longer trust the QIOs to deliver on their promise of a functional, reliable abstraction tool. Although it will be difficult to quantify the effect of these delays on contract performance, the QIOs cannot be held responsible for a 50% improvement in hospital self-reporting under these circumstances. Communications QIOSC To date, due to CMS’ actions and inactions, QIOs have neither the staff nor SOW7 QIOSC support to do the work required under Task 2a. As of this writing, CMS has not yet issued an RFP to select a Communications QIOSC. Simultaneously, upon award of the SOW contracts, CMS provided insufficient funds to continue to support the level of QIO communications staff employed during the Sixth Scope of Work – when communications and outreach were less critical to the Administrator’s priorities. QIOs relied on CMS’ assurances that they could use QIOSC-developed marketing and communication products during the SOW7 and consequently laid off many of their communications staff. Based on an AHQA survey of QIO Communication Directors, the promise of a Communications QIOSC played a significant role in QIO's reductions of communications staff. Thirty QIOs responded to the survey and reported that 24.5 FTEs were lost from the level in the Sixth Scope of Work. This puts QIOs at an obvious disadvantage as they attempt to perform successfully under contracts that require a significant new level of outreach to providers, consumers and the media under several new public reporting efforts. CMS officials have told the QIOs repeatedly that they must rely on efficiencies, centralization and QIO-wide knowledge sharing. The QIOSCs are supposed to be an important element of this effort. The Communications QIOSC is particularly important to QIOs in the Seventh Scope due to the thousands of additional providers and millions of additional consumers the QIOs must reach in order to be successful. This is an area in which reinventing the wheel could be very costly both monetarily and in implementing CMS’ highest priority contract subtasks. Refinements in the evaluation for Task 2a are unlikely to compensate for the failure to fund and provide support to CMS’ contractors, but CMS must take into account in the evaluation its failure to provide a Communications QIOSC. The Task 2a evaluation is perceived to be highly subjective, and therefore difficult to calibrate. At the same time, expectations could hardly be higher. The Nursing Home Quality Initiative was promoted by the Secretary of the Department of Health and Human Services and the CMS Administrator and made national news. The QIOs must fare well under this spotlight. It is critical that CMS issue an RFP and contract with a qualified Communications QIOSC immediately. PARTner Reporting System – Monthly Reports and Project Plans The SOW7 contract requires QIOs to submit information regarding their ongoing activities using the PARTner reporting system. The system was expected to be up and running shortly after the Round 1 QIOs signed their contracts. PARTner was not released, however, until the end of November and still had some components missing at that time. The system was not actually useable until mid-December. Furthermore, while the guide for reporting information into PARTner for Task 1a was finally made available via SDPS memo on December 31, 2002, similar instructions for other subtasks have not yet been issued. This has caused QIOs to miss several months worth of reports and project plan deadlines, but no decision has been made regarding what QIOs should do about missed data due to the delay of PARTner. We strongly recommend that CMS make this decision and then hold QIOs harmless for a failure to report before PARTner became fully operational. CMS must properly account for any additional cost associated with retroactive report submission should it be required. We recommend that QIOs be informed in writing that they are relieved of any obligation to reformat and submit reports that could not be filed during the period that PARTner was not fully functional. PARTner Reporting System – QIO Work Plan The PARTner system was also supposed to accommodate the submission of each QIO’s work plan. Under the contract, the work plan was due 60 days after each QIO’s contract effective date, but months after most contracts were signed, PARTner remained unavailable. In the meantime, QIOs submitted their draft work plans into a temporary Standard Electronic File Folder (SEFF). Additionally, the QIOs were required under their contracts to use the CMS template for their work plans, but it was only available in draft form. The December 26, 2002 SDPS memo regarding the expected contract modification eliminates the work plan requirement, but AHQA has learned that at least one Regional Office still intends to require QIOs in that region to maintain a workplan and produce it for their inspection during site visits. We support CMS adopting a uniform, national decision regarding the workplan requirement. However, if ROs are permitted to insist that contractors maintain a workplan, CMS should state clearly that the faithful execution of that workplan would be considered during evaluation as evidence of a QIO’s progress and as proof of changes in their approach to address any problems they encounter during their work. Additionally, even though the workplan requirements are going to be eliminated, we recommend that CMS notify QIOs that they will be held harmless for their inability to comply with the contractual requirement to submit the work plan while it was required and while a workable template and PARTner were unavailable. GTL/QIOSC Changes in Deliverables In the absence of timely decisions by CMS, Government Task Leaders (GTLs) have been telling QIOs to act upon expected contract changes. This practice has been troubling because QIOs are acting upon changes that are not yet reflected during periods when CMS has provided no official relief from contract deliverable deadlines that are rapidly approaching. We understand that CMS is working to resolve this problem, but QIOs are at risk of failing to conform to certain contract requirements while the process unfolds. Examples of expected changes in deliverables include the following: Home health project plan: Some QIOs have heard from the GTL that this deliverable will be due in five months after the contract start date rather than the contract’s four-month requirement. The latest proposed contract modification, however, does not contain this change. In this case, the GTL’s prediction seems not to have been borne out. List of home health participants: CMS has confirmed the GTL’s prediction in its proposed contract modification by eliminating the required six-month "lock-in" period for participants. Some QIOs could still find themselves in apparent non-compliance with their current contracts at the six-month deadline if the final contract modification is not issued in a timely manner. Furthermore, if QIOs are going to be expected to continue their recruitment of home health agencies throughout the SOW7, as the GTL has stated, CMS must provide sufficient resources for this continued cost. Nursing home chain proposal: While this proposal may yield good results, it has taken CMS and nursing home chain management several months to reach decisions on the content of this policy. As a result, the RFP for interested Lead QIOs to implement this effort was only issued this month. QIOs remain unclear about this proposal’s effect on their recruitment of identified participants and their overall evaluation if they have one or more of the participating chains in their state. We request that CMS provide prompt and official answers to these questions prior to the identified participant group deadline in February. Review Services: The volume of charts that the GTL and QIOSC expected would have to be reviewed as part of the effort to ensure inter-rater reliability (IRR) is now confirmed in the proposed contract modification. However, it also confirms the QIOs’ fear that the amount of work necessary to this volume of reviews will far exceed contract resources. Delay of NHQI Rollout The full impact of the delay of the NHQI rollout on QIO staff resources will not be known until the QIOs begin to reach their 75% spending mark. To prepare for the high profile nursing home quality initiative rollout while conserving resources, many QIOs budgeted their FTEs carefully to transition from one topic to another immediately following the short-term spike in effort necessary for the rollout. The delay, which was stretched out from October 23 to November 14, with no clear expectation of a definite date, caused some QIOs to extend paid time of these personnel. While these circumstances are beyond their control under the contract, QIOs are accountable for downgraded performance and reduced fee as a result of delays in executing work under other subtasks due to staff remaining engaged in a task that was scheduled for completion. Some allowance must be made for the ripple effect of CMS’ delay on the performance of other work. In closing, AHQA acknowledges that CMS is attempting many unprecedented initiatives, and is encountering unexpected difficulties in the course of doing so. We do not expect CMS to be flawless in executing its obligations under the contract. We do ask that CMS recognize that its performance and timeliness has and will have a profound impact on the performance of QIO contractors, particularly where the contract specifies reliance on CMS deliverables that are not available on schedule. We ask CMS to acknowledge that it would be inappropriate for delays or failures in these government deliverables to force competitive renewals and reduced payment of award fees under the contract that would not have occurred if CMS’ deliverables had been timely and fully functional and to adjust its evaluation accordingly. Our recommendations are offered in the spirit of a cooperative effort between the federal government and its contractors, both of which are jointly engaged in an ambitious and worthwhile effort to improve the quality of health care for older and disabled Americans. Thank you for your attention to these matters. AHQA leaders and staff look forward to meeting with you in Baltimore on January 10, 2003 to further discuss these problems and their solutions. Sincerely, David G. Schulke Executive Vice President cc: Stephen Jencks, M.D.