Medicares QIO Program: Maximizing Potential, Making a Difference

1
Medicares QIO ProgramMaximizing
Potential,Making a Difference

• Barry M. Straube, M.D.
• Centers for Medicare Medicaid Services
• AHQA 2007 Annual Meeting
• February 13, 2007

2
IOM Pathways to Quality Health Care

• Performance Measurement
• Accelerating Improvement
• (December 1, 2005)
• Medicares Quality Improvement Organization
  Program
• Maximizing Potential
• (March 9, 2006)
• Rewarding Provider Performance
• Aligning Incentives in Medicare
• (September 21, 2006)

3
Medicares QIO ProgramKey Conclusions

• The quality of health care received by Medicare
  beneficiaries has improved over time
• Existing evidence is inadequate to determine to
  determine the extent to which QIO Program has
  contributed to those improvements
• The QIO Program provides a potentially valuable
  nationwide infrastructure dedicated to promoting
  quality healthcare

4
Medicares QIO ProgramKey Conclusions

• The value of the Program could be enhanced
  through use of strategies to
• Focus QIOs on provision of technical assistance
  in support of quality improvement
• Broaden QIO governance structure and base
• Improve CMSs management of related data systems
  and program evaluations

5
Technical Assistance

• Studies have been inadequate to attribute QIO
  activities to improvements in quality of care in
  Medicare
• Not limited to QIO Program
• Regardless, scrutiny is on the QIO Program to
  lead in demonstrating attribution
• There appears to be some evidence that some QIOs
  perform better than others
• CMS performance evaluation doesnt address
• Individual QIOs dont set/publish their own
  metrics

6
Technical Assistance

• Technical assistance will be imperative as
• A national performance measurement system
  proceeds
• Payments increasingly reward quality improvement
• Strong focus on TA and more vigorous evaluation
  of current future program efforts needed for
  future decisions about the QIO Program
• Similar evaluations needed for other quality
  organizations that might be considered for QIO
  Program activities

7
Structural Issues

• QIO Board Composition, Functions and Structure
• Most boards have only 1 (mandated) consumer
  member
• Inadequate representation of individuals with
  required expertise, beyond physicians, or
  individuals beyond the healthcare field
• Insufficient tools for evaluation of board
  members and the Board as a whole
• Lack of committees for finance, auditing, and
  strategic planning
• Adequate transparency

8
Structural Issues

• Physician-Access or Physician-Sponsored
  Organizations
• Requirements for local physician involvement is
  outmoded
• Focuses on outliers rather than raising all
  boats
• Conflicts of interest
• Restriction from doing business with healthcare
  stakeholders in same state should be re-evaluated
• Confidentiality restrictions
• Reflect protective attitudes of predecessor
  programs and provider interests should reflect
  transparency trends

9
Structural Issues

• 7th 8th SOW primary functions
• Technical assistance through collaboratives or
  other interventions
• Process redesign
• Data collection interpretation for internal QI
• Dissemination activities related to publicly
  available comparative quality data
• Provide education and communication for
  beneficiaries
• Protect beneficiaries and Trust Fund by reviewing
  complaints and appeals, reviewing other case
  reviews to estimate payment error rates and
  address other billing concerns

10
Structural Issues

• A variety of conundrums exist
• Hostile provider attitudes and a reluctance to
  participate in QIO activities
• Possible conflicts of interest that could limit
  QIOs aggressive pursuit of complaints, appeals
  and problematic cases
• Inefficient operations concerning staffing,
  particularly physicians and nurses who are needed
  24/7 to respond to urgent appeals review

11
Structural Issues

• QIOs would have greater value if they
  concentrated their limited resources on the
  provision of technical assistance to support
  performance measurement and quality
  improvement.The regulatory functions of the
  various case reviews should not remain in the
  core SOW for every QIO and should devolve to
  other appropriate organizations.
• IOM Committee

12
CMS Management

• Lack of Program priorities
• Individual tasks specified in great detail, no
  overall priorities
• Evaluation formulas complex and of little help
  to QIOs
• Strategic planning
• Need more emphasis on integrated care
• Quality and efficiency measures should address
  care in multiple settings
• Alignment of measures, QIO Program, P4P
  transparency

13
CMS Management

• Lack of an overall Program evaluation
• Overly complex contract performance evaluations
• Lack of evaluation of the QIOSCs and other
  contracts
• Slow data processing
• Late issuance of the 8th SOW
• Three-Year Contract Length

14
IOM Recommendations

• Recommendation 1 QIO Program should become an
  integral part of strategies for future
  performance measurement and improvement in the US
  healthcare system.
• Congress, HHS, CMS, etc., should strengthen and
  reform key elements of the Program
• Emphasis of QIOs should be on TA
• Patient-centered care across the continuum

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IOM Recommendations

• Recommendation 2 QIOs should encourage all
  providers to pursue quality improvement
• Assist all who request assistance
• Prioritize to those who need assistance most or
  who face significant challenges
• Recommendation 3 Congress and CMS should reform
  the organizational structure and governance of
  QIOs

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IOM Recommendations

• Recommendation 4 Congress and CMS should
  develop other mechanisms to handle beneficiary
  complaints and appeals, as well as other case
  reviews
• Recommendation 5 HHS and CMS should revise QIO
  data-handling processes to be more timely,
  efficient and useful

17
IOM Recommendations

• Recommendation 6 CMS should set clear goals and
  strategic priorities for the QIO Program and
  implement core contract changes
• Coherent and feasible scope of work
• Incentives for broader dissemination of rapid QI
  interventions
• At least one local quality intitiative on basis
  of demonstrated need

18
IOM Recommendations

• Recommendation 6 (cont)
• Strong incentives and penalties for QIO
  performance
• Extension of contracts from 3-5 years
• Greater competition for each new contract
• Consistent performance periods
• Timetable for goal setting, program planning, and
  funding processes
• QIOSC, Special Studies, support services should
  reflect specific goals/priorities of the Program
• Greater collaboration between CMS AHRQ
• Greater communication between CMS components
  QIOs

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IOM Recommendations

• Recommendation 7 CMS should develop four types
  of evaluation to assess the Program
• The Program as a whole
• Individual QIOs with respect to the core contract
• Selected quality improvement interventions
  implemented by QIOs
• An independent, external evaluation of the QIO
  Programs effectiveness contributions

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IOM Recommendations

• Recommendation 8 Congress and Secretary of HHS
  should focus the QIO apportionment on supporting
  quality measurement and improvement, separating
  out case review, appeals complaints. Remaining
  funds should be re-examined for effects of
  inflation, increase in work, etc.
• Ease conflict of interest restrictions, as well
  as increase competition opportunities

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But Its Not Just About IOM

• New leadership at CMS
• Management, process, metrics, evaluations,
  accountability have been sorely lacking
• Senate Finance Committee
• Has a more critical view of governance, conflict
  of interest, travel, conferences, etc.
• Comes from the vantage point of wanting to assure
  that Medicare Trust Fund dollars are not being
  wasted or used for purposes other than improving
  quality for Medicare beneficiaries
• The Congress as a whole, in tight budget times
• Healthcare Expenditures increasing, quality is not

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But Its Not Just About IOM

• Office of Management Budget
• Priority of cutting waste in expenditures,
  promoting competition
• Value of dollars spent
• Accountability in real-time, metrics and
  performance evaluation
• DHHS
• Multiple priorities of the Secretary and other
  HHS components need to be reflected and
  considered in the QIO Program
• The print and broadcast media
• Multiple outside healthcare organizations who
  participate in the quality arena They need
  resources, think they can do as well or better

23
State of the QIO Program 2007

• Integral Part of healthcare quality movement
• Broad, yet tentative and expectant, support
• Administration, the Secretary CMS Administrator
  see QIOs as such a vehicle and foundation to
  support Transparency and Value-driven healthcare
• Availability of quality information
• Availability of cost/price information
• Promotion/adoption of HIT
• Creation of incentives for high-quality,
  efficient healthcare

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State of the QIO Program 2007

• Integral Part of healthcare quality movement
• BQI Pilot roles, Value Exchanges, Community
  Leaders Programs
• Quality Alliances AQA, HQA, QASC
• Other federal agencies
• Leading healthcare quality organizations IHI,
  NQF, NCQA, etc.
• There are other viewpoints, questioning the value
• Need to demonstrate value in areas of obvious
  vulnerability

25
State of the QIO Program 2007

• Offering TA to all providers
• Have met/exceeded recruitment goals on many of
  subtasks
• Doesnt address
• Reluctant audience
• Audience that doesnt see value, rightly or
  wrongly
• Audience with greatest need, whether
  resource-driven or poor-performance-driven
• Resource use questions
• Variation in resources expended by QIO-why?
• Efficiency evaluation and monitoring needed
• Clear-cut goals, objectives, metrics, evaluation

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State of the QIO Program 2007

• Reform of QIO organizational structure and
  governance
• CMS site visits performed in CA, FL, NJ
• AHQA voluntary guidelines Dont go far enough to
  address all governance issues
• CMS has pursued administrative, regulatory and
  legislative processes and issues involved with
  changing structure and governance
• Individual QIOs and their Boards have and can
  independently implement reform
• Broader Board representation, including consumers

27
State of the QIO Program 2007

• Individual QIOs and their Boards have and can
  independently implement reform
• Expansion of areas of expertise multiple health
  disciplines, group purchasers, IT professionals,
  etc.
• Greater inclusion of QI experts from outside
  healthcare and from the local community
• Committee structure strengthening, development
  plans for individual members, annual performance
  evaluations, annual assessments of Board
  performance as well as improvement plans
• Public posting of Board membership along with
  compensation paid to members and the CEO

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State of the QIO Program 2007

• Alternate models of handling complaints, appeals
  and case review functions
• State-by-state process inheritantly inefficient
  and potentially inconsistent
• Current volumes seem low, knowledge of the
  process not widespread
• Focus should be on identifying system
  improvement, not primarily addressing individual
  cases
• CMS has begun initial analysis of volume,
  quality, costs and efficiency, legal, and
  outcomes of these functions
• Wide variations in expenditures to process cases
  needs evaluation
• QIOs have independently combined efforts for
  handling BIPA/Grijalva appeals with shared staff
• CMS is exploring issues concerning sharing of
  more information at conclusion of investigations

29
State of the QIO Program 2007

• QIO Data Handling
• Woefully inadequate, for QIOs and CMS
• Timeliness issues
• Security, privacy, and quality of process issues
• Validation issues
• Customer-service focus needs to be embraced
• CMS has begun an evaluation of all aspects of the
  data systems process, both at CMS Central Office,
  as well as at the contractor level
• Related issues to Quality Alliances, Hospital and
  other provider reporting initiatives, providing
  Medicare data (as statute allows) to the larger
  healthcare community, etc.

30
State of the QIO Program 2007

• QIO Program Management
• Complete reassessment performed prior to IOM
  Report, the latter aligning and complementing, in
  many instances
• Departmental involvement in response to IOM
  report
• Initial changes to some major flaws in incipient
  8th SOW, ongoing discussions for additional
  changes
• CMS Central Office staffing changes
• Recruiting for QIG Director and other individuals
  to focus on managing the QIO Program effectively

31
State of the QIO Program 2007

• QIO Program Management
• Broadening of management oversight at the level
  of the Director Deputy Director of OCSQ, as
  well as to the level of the Administrator of CMS
  at CMS Quality Council
• Formation of the Business Operations Support
  Group (BOS) in OCSQ
• Budget oversight
• Contracting
• Communications now centralized and staffed
  appropriately
• Inclusion of other OCSQ Groups, CMS components,
  CMS Regional Offices, other HHS OPDIVS in the
  overall QIO Program management structure

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State of the QIO Program 2007

• QIO Program Management
• Initial development of performance metrics and
  processes for CMS staff in program management
• Training of Project Officers, GTLs, Contract
  Officers, and others in basic oversight and QIO
  assistance tasks
• CMS Deputy Director led administrative oversight
  mentoring visits to CA, FL, NJ with resulting
  best practices identified
• Senior management dialogue initiated with AHQA
  leadership

33
State of the QIO Program 2007

• QIO Program Management
• Bi-monthly meetings with QIO CEOs and staff via
  videoconference initiated
• QualNet 2006 Conference broadened to include
  senior leadership participation and outside
  healthcare stakeholder participation
• CMS Annual Report to Congress on QIO Program
  separated out from CMS CFO RTC
• CMS Deputy Director initiated QIOSC review with
  site visits to IA, WA, PA
• Review of Special Studies and support budgets
  initiated

34
State of the QIO Program 2007

• Program Evaluations
• Internal performance metrics delineated for
  program management
• Analysis of 6th 8th SOW evaluations performed
• Confirm IOM Report
• CMS working with ASPE, ASRT, ASL, and other HHS
  agencies to develop a rigorous set of evaluation
  processes for all aspects of the Program
• Have been seeking input and informal
  recommendations via existing quality alliance and
  other healthcare stakeholder activities in the
  QIO Program

35
State of the QIO Program 2007

• QIO Program Funding
• Currently 10 per beneficiary per year for all
  QIO activities
• 0.1 of Medicare expenditures on healthcare
• Private sector spends an estimated1-2 on quality
  improvement activities
• There are definitely inefficiencies in the
  current Program that need to be addressed
• There is also a question of value (or lack
  thereof) for current expenditures
• Departmental OMB approval of ongoing budget
  funds will rest on demonstrating improving
  outcomes of defined goals and objectives,
  attribution to QIO interventions, value and
  efficiency, and responsible use of Medicare Trust
  Funds.

36
State of the QIO Program 2007

• Overall Conclusions
• We have begun to address many of the IOM
  Recommendations already and made a significant
  start
• In spite of structural weaknesses in the Program,
  progress is being made on all sutasks, albeit
  with some degree of variability by subtask and by
  QIO
• 9th SOW planning has begun with all of the
  aforementioned being considered, and theres
  lots to be done yet

37
9th SOW Planning

• Has been ongoing since the beginning of the 8th
  SOW, now increasing
• Goal is to address, as appropriate and as
  possible, all of the various critiques of and
  recommendations to the Program
• The federal clearance process, the public nature
  of the Program, the seriousness of issues were
  facing, make the process more deliberative than a
  private-sector corporate process

38
9th SOW Planning

• Rough concept framework development
• Ongoing
• Recently presented to the CMS Administrator
• Taken to Departmental leadership earlier than in
  past to collaborate and revise the concept
• August 1, 2008 is statute-mandated start date
• Paramount is need to
• Implement needed reforms
• Have structure, content and support processes in
  place prior to contract start date

39
9th SOW Planning

• Leadership Group within HHS providing guidance to
  the framework and reform
• Structure Work Group
• Content Work Group
• New timeline being devised
• Appropriate briefings and clearance points being
  delineated
• Problems of implementing needed reforms and
  achieving start date being assessed

40
Secretarial Priorities 2007-2008

• Value-Driven Healthcare
• Health Information Technology
• Medicare Prescription Drugs
• Medicaid Modernization
• Louisiana Health Care System

• Personalized Health Care
• Prevention
• Pandemic Preparedness
• Emergency Response Commissioned Corps Renewal

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Potential Themes for 9th SOW

• Need to incorporate the Secretarys priorities
  and CMS Administrators priorities, as well as
  aligning with other national healthcare
  priorities
• Prevention
• Patient Safety
• Patient Pathways
• Avoidable hospitalizations and re-hospitalizations
  
• Transitions across settings of care
• Hospice and palliative care
• All heavily dependent on Transparency,
  Value-Driven Healthcare, P4P and HIT
• Also can incorporate health disparities,
  geographic variations, etc.

42
Contact Information

• Barry M. Straube, M.D.
• CMS Chief Medical Officer
• Director, Office of Clinical Standards Quality
• Centers for Medicare Medicaid Services
• 7500 Security Boulevard
• Baltimore, MD 21244
• Email Barry.Straube_at_cms.hhs.gov
• Phone [phone]