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CLINICAL COMMENTARY
Assuring Quality in Senior Care: PROs, SOWs, and QIOs
Gerard W. Frank, M. D., Ph. D.?
Medicare came into existence almost forty years ago. A sardonic New Yorker cartoon at the time pictured a
nurse telling a disgruntled physician: \"Doctor, you must stop referring to your Medicare patients as
comrades!\" Ironically, the subsequent growth and evolution of the program was as unexpected as the
fate that befell the former Soviet Union. Today, Medicare is far and away the prime financier of
healthcare, and the practice of medicine (as well as the teaching of medicine) as we know it in the United
States, would be unthinkable without it.
From its inception, the Medicare Administration (then HCFA, now Centers for Medicare and Medicaid
Services, or CMS) created mechanisms to assure the quality and appropriateness of the care delivered, and
to prevent fraud and abuse as well. Initially, a system of so-called Professional Standards Review
Organizations (PSROs) hired physicians to review problem cases. They operated locally and in
California numbered in the hundreds. The medical community tended to view PRSOs as intrusive and
pressure for change led to the Peer Review Improvement Act of 1982. This established a system
in which the government contracts with statewide entities, originally known as Peer Review
Organizations (PROs). The current administration in Washington has changed this designation to Quality
Improvement Organizations (QIOs).
The QIO in California has, since the beginning of the program, been CMRI (California Medical Review,
Inc.?). While CMRI is not-for-profit, the QIOs in some states are private for-profit corporations.
CMRI, in fact, is a physician-membership corpora-tion. Any California physician can belong, dues-free.
As such, the physician membership elects physicians to the governing board (a total of 12 from 6 state
regions) and approves the corporation\'s by-laws. The CMRI board also includes representatives from
Medicare beneficiaries, hospitals, nursing homes, and entities such as the Pacific Business Group on Health.
CMRI also maintains a panel of over 350 physician experts to do case review, and any licensed physician
may apply to serve on that panel.
Early on, the QIOs focused on utilization and appro-priateness of care, primarily to insure that the system
was not paying for inappropriate hospital admissions. In 1986, Congress -responding to concerns about the
quality of the care delivered to the Medicare benefici-aries -amended the law, mandating review of \"quality
of services\" in hospitals but also including \"post-acute-care settings, ambulatory settings, and health
maintenance organizations.\" 1 One year later, Congress funded that mandate and the growth of
involvement by the QIOs in reviewing and promoting quality of care began a steady increase. 2
The work of the QIOs in the Medicare program has been structured through consecutive 3-year contracts,
each contract termed a \"Scope of Work\" (SOW). The program is presently operating under the seventh
SOW. The scope is broad, and includes promotion of clinical guidelines to both the healthcare community
and the Medicare patients, the \"beneficiaries\" of the program. Review activity by the QIOs responds to
patient complaints and other perceived problems in quality of care rendered by hospitals, and other
providers. The seventh SOW continues the program\'s move into the outpatient, nursing home and home
health arenas.
Quality Improvement
Hospitals
This initiative encompasses all of California\'s 384 hospitals with a target of an 8% improvement in
overall performance measures in 4 clinical situations. For Acute Myocardial Infarction, the indicators
include administration of aspirin, beta-blockers and ACE inhibitors. Rapid initiation of reperfusion
therapy and counseling of smoking cessation are addi-tional indicators to be measured. Indicators in Congestive Heart Failure include echocardiographic assessment of left ventricular function, ACE inhibitor
use, counseling of smoking cessation and instructions at discharge. For Community Acquired Pneumonia,
the use of blood cultures, promptness of antibiotic administration, consistency of antibiotics with current
guidelines, and vaccination against the pneumococcus and influenza virus (in season) are the performance
indicators. Finally, the choice, timing and duration of antibiotics in the Prevention of Surgical Infections
will be assessed.
In the seventh scope of work, hospitals will be gener-ating their own data for assessment by the QIO with
the goal of greatly increasing the number of hospitals collecting and submitting data. A key component of
hospital participation is the identification of physician \"champions\" to provide leadership and promote
medical staff buy-in to the improvement strategies.
Nursing Homes
A 10% sample of California\'s approximately 1400
eligible nursing facilities will be assessed with regard to pain management and pressure ulcers. These facil-ities
already are required to submit patient data elec-tronically to CMS at defined time intervals. A target
of 8% improvement in overall performance over the course of the project has been set, with measurable
improvement in at least 80% of the participating facil-ities. This project requires partnerships with the
various trade associations in the Nursing Home Industry. CMRI will run training programs for
Nursing Home staff in quality improvement method-ology.
Home Health
California has over 500 Home Health agencies.
Significant improvement must be achieved in 30% of these agencies using CMS\'s Outcome and Assessment
Information Set (OASIS). OASIS includes 41 different outcome measures of quality improvement.
An extensive training program is in process to Home Health personnel in QI techniques.
Physicians\' Offices
This is a project being piloted in California and two
other states and focusing on chronic disease manage-ment and preventive services. Targeted conditions
include chronic stable coronary disease, adult diabetes, hypertension, major depression, heart
failure, and osteoarthritis. Quality improvement using clinical guidelines, analysis of systems of care,
looking at access and patient satisfaction, will be measured. Methods of incentivizing physicians to
improve quality in their offices (CME credits, public recognition, risk/ liability reduction) will also be
compared. The goal of this study is to collect data from 25,000 of the California\'s licensed physicians. A
key component of this initiative will be electronic
submittal of quality data from physicians\' offices, a project entitled DOQ-IT, which will be tied to intro-duction
of electronic medical record systems and will include partnership with the American Association of
Family Physicians.
Underserved and Rural Populations
The goal of this initiative in California is improve-ment
in the use of an annual HbA1c test among Latino diabetics, reducing the disparity of practice
relative to the non-minority population (estimated to be about 7%). Given that this state has over 200,000
Latino Medicare beneficiaries, with a higher preva-lence of diabetes, success in this task would have
substantial impact in medical care. In addition to collecting data from providers in the 4 counties with
the highest number of senior Latinos (Los Angeles, Riverside, Orange and San Diego) this initiative will
be promoted in newspapers and media stations in the Latino community.
Medicare+ Choice Programs
All of the managed care plans enrolling Medicare
beneficiaries (currently 13 plans in California) are required by CMS to initiate projects in Quality
Assessment Performance Improvement (QAPI). The plans will be invited to participate in support
programs by CMRI which will provide technical assistance in meeting the goals of their QAPI projects.
This will be integrated with other CMS projects already in place and has as a goal to decrease the
burden of QI activity on physicians and hospitals.
Review Activities
Beneficiary Complaints
The QIOs have for many years had the task of responding to complaints from Medicare patients or
their families about quality of care issues. After peer review of the medical records pertinent to the
complaint, the QIO is expected to take appropriate action as necessary to address its findings. In working
with beneficiaries, a case management approach is used, focusing on communication with the
complainant in an educational and supportive manner. This program is monitored for timeliness, reliability,
consistency between reviewers and patient satisfac-tion with the complaint management process.
Physicians and hospitals have naturally been concerned with issues of confidentiality and fairness
in such a process. These concerns have recently
increased as a result of the Public Citizen v. Thompson case, which was heard in a Federal Court.
The husband of an elderly woman who died of colon cancer filed a complaint with a QIO alleging delay in
the diagnosis of her tumor. The QIO\'s review found no significant deviations from standard of care. The
husband was simply informed that the complaint had received review and disposition had been made. He
then sued Centers for Medicare and Medicaid Services (with the aid of the American Civil Liberties
Union) alleging that a more detailed disclosure of the review and its findings should be made available to
him.
At issue was whether or not the QIO process, requiring a physician\'s consent before any findings
about that physician could be released to a benefi-ciary, was consistent with the legislative intent of the
1986 law. The court decided that it was not, and that the complainant had to receive a notice of final dispo-sition
with or without physician consent. The require-ment to maintain confidentiality of peer review delib-erations,
etc., has not changed as a result of the court\'s decision.
CMS and the QIOs are still in the process of deter-mining exactly what satisfies the terms of the
mandated disclosure and its relation to discoverability during malpractice litigation. Complainants are being
informed if care met professional standards or not, but any detailed information about the review\'s findings is
released only with the involved physician\'s consent. The QIO\'s focus in this process is to emphasize
opportunities for quality improvement rather than accusation, recognizing that the majority of medical
errors occur in the context of complex delivery systems.
Mediation as an Alternative
Experience from other sectors of the economy
suggests that mediation may be a more satisfactory method of dealing with complaints from Medicare
beneficiaries against physicians or other providers. It has been noted that upwards of 80% of Medicare
beneficiary complaints are related to misunderstand-ings, lack of communication or the patient\'s percep-tion
of treatment. CMS has already conducted a pilot study of complaint mediation. In that study, 17 cases
were mediated in California. In all but one case, a constructive result was achieved with high levels of
satisfaction in both patients and physicians. CMS has
decided to broaden this initiative in all the QIOs. In general, it is anticipated that mediation will be most
appropriately applied when review of a complaint fails to indicate any substantive quality of care
problem. This restriction, it is hoped, will gain physi-cian acceptance, as reportable monetary settlements
are very unlikely to result. General application of mediation in serious medical disputes is somewhat
more problematic. 3 The process will be completely confidential, with no written record of the proceeding.
Such discussions are not considered admissible in court under both Federal and California law.
Other Mandated Reviews
The QIOs are mandated to review cases referred for
possible violations of the Emergency Medical Treatment and Active Labor Act (EMTALA) with
regard to transfers of patients between facilities. These reviews are carried out by physicians board
certified in Emergency Medicine. Other mandated reviews include hospital requests for higher-weighted
DRG adjustments in payment, admissions to hospital for less than 24 hours, and claims by Medicare bene-ficiaries
of premature discharge from hospital. Other governmental agencies (e. g., Department of Justice,
Office of the Inspector General) may at time also refer specified cases to the QIOs to review. Physicians may
receive letters requesting justification of medical necessity as a result of these reviews.
This update has focused on QIO activities which directly impact physicians who care for Medicare
beneficiaries. Space does not permit details about QIO educational activity in the beneficiary population
and involvement with the many community organiza-tions serving that population, but these are consider-able.
Physicians have many opportunities to be proactive in the process of quality improvement.
CMS clearly regards it as an essential part of deliv-ering care.
?The author is a member of the CMRI Board of Directors.
?CMRI is in the process of changing its name to Lumetra.
REFERENCES
1. 42 U. S. C. 1320, P. L. 99-509 ? 9353.
2. 42 U. S. C. 1395 ? 4097.
3. Dauer EA, Marcus LJ, Payne SM. Prometheus and the litigators. A
mediation idyssey. J Leg Med. 2000 Jun; 21( 2): 159-86.
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