Bill Title: Medicare Quality Improvement Organization Modernization Act of 2007

Sponsor: U.S. Congressman Michael Burgess, M.D. (TX-26)

Introduced: Wednesday, February 14, 2007

Status: Introduced in the House.

Why it is needed: In 2006, the Institutes of Medicine made several recommendations on how to improve the coordination of quality improvement activities of Medicare QIOs and improve program accountability.

Under the direction of CMS, the Quality Improvement Organization (QIO) Program consists of a national network of 53 QIOs, responsible for each U.S. state, territory, and the District of Columbia. QIOs work with consumers and physicians, hospitals, and other caregivers to refine care delivery systems to make sure patients get the right care at the right time, particularly patients from underserved populations. The Program also safeguards the integrity of the Medicare Trust Fund by ensuring that payment is made only for medically necessary services, and investigates beneficiary complaints about quality of care.

The IOM report made several specific recommendations to improve how QIOs work. These recommendations include:

· Strengthening evaluation design to better assess the impact of the Program

· Strengthening financial oversight and establishing requirements for QIO board governance to assure appropriate use of contractor funds and the representation of key constituencies

· Increasing competition for QIO contracts

· Enabling QIOs to release information to beneficiaries about QIO findings related to their complaints

· Directing QIOs to focus on the local achievement of national quality and efficiency goals, to improve care for beneficiaries with significant medical needs

· Directing QIOs to support local initiatives to develop and use information on quality and cost to help beneficiaries, their caregivers, and their health professionals make better choices about their treatment options, and self-care

What it does: The bill would improve and modernize Medicare through contracts with Quality Improvement Organizations (QIOs). QIOs would compete for contracts to provide quality assistance. The bill would improve how QIOs interface with patients and providers by providing detailed feedback based on beneficiary complaints and work to improve the quality of health care services. In terms of quality improvement assistance, QIOs would improve data collection, assistance and guidance on Health Information Technology, and assist providers in the improvement of care in rural and frontier areas as well as attempting to reduce racial, ethnic, and gender disparities.

Hypothetical example: Texas Medical Foundation, the QIO that serves Texas Medicare providers and beneficiaries could improve their interaction with patients when a complaint occurs as well as working with providers on a more proactive basis to improve the baseline of quality care provided in a multitude of settings. This bill will also give organizations like Texas Medical Foundation more flexibility within their contracts with CMS to adapt to changing expectations and allow them to more responsive to beneficiary complaints through the term of the contract.

Specifics on Medicare QIO Modernization Act of 2007:

Seeks to improve and modernize Medicare through contracts with Quality Improvement Organizations (QIOs).

- QIOs would compete for contracts to provide quality assistance.

- They will offer quality improvement assistance to healthcare providers, physicians, Medicare Advantage organizations, and prescription drug sponsors

Examples of quality improvement assistance:

- instruction on collecting, submitting, and interpreting data

- technical assistance in beneficiary education

- facilitating adoption of procedures that encourage timely feedback from patients

- guidance on redesigning clinical processes, including use of health information technology (HIT)

- assistance in improving rural and frontier care, as well as reducing racial, ethnic, and gender disparities

- assistance in improving coordination of care among different providers

Each QIO will organize a ‘Medicare quality accountability program’ that collects patient feedback on the care they have received.

Examples of what a Medicare quality accountability program would do:

- educate Medicare beneficiaries of standard quality measures and their rights to voice quality concerns

- report investigation findings to the patient (these may not be used in any form in a medical malpractice action)

- help providers choose methods for gaining feedback from patients

- remedies confirmed complaints

- helps providers fix quality problems or refers them to enforcement providers if they are unwilling or unable to improve

- publishes annual quality reports in each state

Details on oversight of this program:

- the Comptroller General of the United States will report on the implementation of this program by March 31, 2010

- QIOs will be provided maximum freedom for innovation in local quality intervention strategies

- a strategic advisory committee (including national quality improvement experts, beneficiary representatives, healthcare providers, and organizations holding contracts) will set national strategic priorities for improving the quality of healthcare, and will update these in time to submit a draft statement of work and funding request for each program cycle

- the QIO will be evaluated by an outside contractor to optimize assessment of program performance

- organizations contracted to the Secretary will be able to share individual-specific data with a physician treating the individual (within HIPAA regulations)

Details of QIO contracts:

- the contract shall be for an initial term of five years and shall be renewable for each 5 years thereafter

- the contract shall be subject to open competition

Aggregate funding under contracts shall not be less than $421,666,000, and at least 80% of this shall be expended in support of core contracts

Groups that Support the Bill:

American Health Quality Association (support letter attached)