Medicare s QIO Program: Maximizing Potential, Making a Difference

1. Medicare�s QIO Program:Maximizing 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) Medicare�s Quality Improvement Organization Program: Maximizing Potential (March 9, 2006) Rewarding Provider Performance: Aligning Incentives in Medicare (September 21, 2006)

3. Medicare�s QIO Program:Key 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. Medicare�s QIO Program:Key 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 CMS�s 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 doesn�t address Individual QIOs don�t 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

15. 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

16. 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 (con�t): 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

19. 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

20. 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

21. But It�s 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

22. But It�s 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

24. 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 Doesn�t address Reluctant audience Audience that doesn�t 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

26. State of the QIO Program: 2007 Reform of QIO organizational structure and governance CMS site visits performed in CA, FL, NJ AHQA voluntary guidelines: Don�t 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

28. 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

32. 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 there�s 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 we�re 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

41. Potential Themes for 9th SOW Need to incorporate the Secretary�s priorities and CMS Administrator�s 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@cms.hhs.gov Phone: (410) 786-6841