Patients deserve info on quality-of-care cases

Regulations prohibit sharing of details

Medicare recipients who have a complaint about their quality of care have a means of reporting their complaints — but it’s unlikely they will find out the details of investigations of their complaints, according to the American Health Quality Association (AHQA), which has launched an effort to enact major reforms in the complaints system.

The Centers for Medicare and Medicaid Services (CMS) investigates complaints by Medicare beneficiaries about quality of care by contracting with quality improvement organizations (QIOs) in each state to actually conduct the investigations. However, CMS prohibits QIOs from telling the complainants details of investigations involving physicians without permission from those physicians. Without permission, QIOs can only tell complainants whether their complaint was confirmed; they cannot reveal what went wrong or why.

AHQA, which represents the national network of QIOs, is proposing 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 happens

According to CMS, QIOs have two methods of resolving clinical quality-of-care beneficiary complaints: medical record review and mediation.

When a case is reviewed for quality issues, one of two determinations is made — either "no substantial improvement opportunities are identified," or "care could have been better."

The Medicare patient is not given details uncovered by the QIO. In cases where it is deemed that care could have been better, the QIO reviewer determines if care was "grossly and flagrantly unacceptable," failed to follow accepted guidelines or usual practice, or could reasonably have been expected to be better. Again, while CMS permits complainants to be kept informed as to the progress of the sometimes months-long investigation, no specifics involving physicians are disclosed.

Cases for which no improvement opportunities are identified or where better care could have been expected can be considered for mediation if the person filing the complaint wants to pursue mediation. Due to the serious implications of cases in which care was grossly or flagrantly unacceptable, or where care failed to follow accepted guidelines or usual practice, those cases are not eligible for handling through mediation.

Medical record review is the traditional option to resolve a quality-of-care complaint under Medicare. When the QIO receives a written complaint about the quality of services received by a Medicare beneficiary, a doctor of matching specialty will review the medical record. When the review is complete, the QIO notifies the complainant of the final disposition of the complaint.

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," says David Schulke, AHQA executive vice president. "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."

"The role of the Medicare QIO program should be to protect the entire population of Medicare beneficiaries, and to support improvement of America’s health care system," says Jonathan Sugarman, MD, AHQA past president and the CEO of Qualis Health, a QIO in Seattle.

"Unfortunately, the current Medicare beneficiary complaint system as regulated by CMS has not been implemented in a manner that focuses on rapid resolution of disputes and systematic improvements in care, and has not kept up with our evolving understanding of quality improvement."

For example, Sugarman points out, CMS does not regularly analyze and report the specific types of quality-of-care concerns that are identified by QIOs, depriving QIOs the opportunity to share data on the quality complaints confirmed nationwide.

"AHQA’s proposal encourages increased transparency to complainants, remediation of systems problems, and prompt referral to appropriate authorities when willful and reckless actions are identified, and it also supports prompt and candid communication between patients and practitioners when complaints arise," Sugarman adds.

Policy part of modernizing QIOs

AHQA’s call to reform the beneficiary complaint program follows the association’s adoption in 2005 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 more than two-thirds of QIOs — sets standards for board and executive compensation, diversity, travel expenses, and conflicts 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.

Details clear the air, may prevent lawsuits

Some efforts at reducing medical errors and contentious malpractice lawsuits hinge on getting information into the hands of those who believe they have suffered a breach in quality of care, not in withholding that information. The Sorry Works! Coalition has been successful in getting several states to pass legislation urging health care providers and hospitals to openly investigate allegations of medical errors, and to share their findings with complainants.

Theorizing that many lawsuits arise out of frustration over not receiving answers about what happened or assurances that measures are taken to prevent repeat occurrences, Sorry Works! and efforts like it work to educate health care providers that openly addressing errors — or allegations of error — can do more to ensure a good outcome than a room full of lawyers. Like the AHQA proposal, Sorry Works! plans contain protections for physicians and other providers so that the information shared cannot be used against them in malpractice actions.


  • Jonathan Sugarman, MD, MPH, CEO Qualis Health, P.O. Box 33400, Seattle, WA 98133. Phone: (206) 364-9700.
  • American Health Quality Association, 1155 21st St. NW, Suite 202, Washington, DC 20036. Phone: (202) 331-5790. Web site:
  • The Sorry Works! Coalition, P.O. Box 531, Glen Carbon, IL 62034. Phone: (618) 559-8168. Web site: