CMS initiates Scope of Work quality program

A new proposal for its quality improvement organizations (QIOs) has been unveiled by the Centers for Medicare & Medicaid Services (CMS). QIOs are local organizations that by law, contract with CMS to provide quality improvement assistance to health care providers, such as physicians, hospitals, nursing homes, and home health agencies, and health plans that contract with Medicare.

Mark McClellan, MD, CMS administrator, said the QIOs are a key part of the center’s efforts to improve the quality of care offered by the U.S. health care system. "We know there are areas where there are substantial gaps between known good practice and actual practice, and we know dramatic improvement is possible," he said. "We now have more opportunities than ever to close those gaps, so that every Medicare beneficiary gets the right care every time he or she receives medical treatment."

Program focuses on three key areas

CMS has proposed what it calls the 8th Scope of Work, calling it a plan that represents significant enhancements over previous QIO contracts. According to CMS, compared to previous contracts, the new proposal is different in three key areas.

1. It recognizes that although the U.S. health care system "has been leading the way in many improvements, the full potential of our health care system to improve health is not being achieved," CMS said. The plan is intended to promote dramatic improvements in the quality of health care so every person receives proper care.

2. The plan proposes that QIOs may need to build on their current efforts to involve other organizations and entities to provide the best expert assistance in increasingly specialized areas, and it invites comments on options for accomplishing that via subcontracting and other partnerships.

3. The design of the program will be organized to better distinguish QIO impact from improvement that may occur without QIO assistance, such as increased awareness of clinical guidelines by physicians.

McClellan said CMS, working with the QIOs, wants to see improvements that could transform the quality of life for Medicare beneficiaries. For example, according to CMS, 27% of people with Medicare did not receive annual flu vaccinations in 2002, vaccinations that could prevent as many as 22,000 deaths annually. McClellan said that under this plan, QIOs will assist in closing the gap between poor performing nursing homes and those practicing right care.

The 8th Scope of Work focuses attention in four settings: nursing homes, home health agencies, hospitals, and physician offices. It also will protect beneficiaries and the Medi-care Trust Fund through work on appeals, beneficiary complaints, payment error, and other case review activities, CMS said.

The agency said the new plan also moves past the 7th Scope of Work in various respects:

• QIOs will work to promote the adoption and effective use of health care information technology, performance measurement, process redesign, and organizational culture change. For example, working with partners in a pilot project, QIOs are assisting small- to medium-sized physician offices in California, Arkansas, Massachusetts, and Utah in adopting office-based electronic health record systems and using the systems to improve efficiency of care delivery, quality of care, and patient safety.

• QIOs will work with prescription drug plans to ensure quality care to people with Medicare on improvement projects such as measures to detect inappropriately prescribed drugs and ways to identify patients who may be at risk for harmful interactions.

• QIOs will work to improve care for disadvantaged populations by focusing on physician office-based care to make sure all Medicare beneficiaries get the right preventive services and appropriate care for chronic diseases such as diabetes.

• QIOs are expected to continue offering mediation as a service to Medicare beneficiaries. The service involves direct provider involvement in responding to beneficiary complaints, which often results in improved communication be-tween provider and patient to resolve quality-of-care issues.

CMS said this multipronged approach includes helping consumers make decisions using timely and accurate quality-of-care information and urging providers to improve quality using free assistance from the QIOs and through pay-for- performance demonstrations.

Beginning in early 2005, hospital quality data will be available at CMS currently publishes quality information on its web site for Medicare and Medicaid-certified nursing homes and Medicare-certified home health agencies. The 8th Scope of Work will guide the work of the QIOs for the three-year cycle beginning in August 2005.

CMS invited public comment on the proposal to assist in developing the full plan and for determining the level of program funding.