A working conference convened by the Center for Medicare Advocacy, Inc., supported by the Commonwealth Fund, a New York City-based private foundation, and AARP

January 19, 2007

I.  Background

In March 2006, the Institute of Medicine released a report, Medicare’s Quality Improvement Organization Program: Maximizing Potential, which, among other suggestions, recommended removing from Quality Improvement Organizations (QIOs) the function of performing quality of care complaint investigations for Medicare beneficiaries. With this background, the Center for Medicare Advocacy, Inc., supported by The Commonwealth Fund and assisted by AARP, convened a one-day working conference on January 19, 2007 to create a model complaint process for Medicare beneficiaries.

II.  The Conference

Forty-two invited experts from a variety of backgrounds attended the conference. Participants reviewed a variety of materials prior to the conference including three papers commissioned by the Center. The first paper presented an overview of the current process as well as its history.
 

The second paper, written by a physician, examined the attributes of an ideal complaint process. The third paper, written by legal professors, explored possible alternative entities that might execute the complaint process.
 

The day was divided into four sessions. In Session I, the authors presented their papers to the participants, providing an overview and background information. In the second session, several experts presented information about beneficiary knowledge about health care. In particular, they highlighted issues of health access and cultural literacy. Session III allowed for the opportunity for all of the participants to speak at length about the various components and important aspects of a complaint review system for Medicare beneficiaries. The lively discussion culminated with Session IV where the Center’s Executive Director, Judith A. Stein, guided conferees through what was said during the day and brought participants together on a consensus model of an ideal beneficiary complaint process.

III.  Summary:  Conference Consensus for Quality Review Model

The areas of participant agreement regarding a model for a Medicare quality review system are briefly outlined below.  The Model is described in more detail in the Narrative of the Conference Proceedings. 
 

1.  Filing Complaints

A.     Definition of “Complaint” Should be Construed Broadly

B.     Anyone Can File a Complaint

C.     Neither Language nor Technology Should Discourage Complaints

2.  Goals of the Complaint Process

A.     The Primary Goal is Addressing Beneficiary Concerns

B.     A Secondary Goal is Identifying Provider Opportunities for Quality Improvement

3.  There Should be a Single Point-of-Entry for Beneficiaries

A.     The PAL

B.     Regulatory Capacity of a “PAL” Single Point-of-Entry Entity

4.  Qualifications of a Quality Review Entity

A.     Intake and Review

B.     Referral

C.     Centralized Database

5.  Possible Referral and Resolution Entities

A.     Providers

B.     State Survey Agencies

C.     State Medical Boards

D.     QIO Retention of Current Role

E.      Other Potential Entities

F.      A Hybrid Approach

6.  Data Should be Gathered and Used for Quality Improvement

7.  The Complaint System Should be Evaluated on a Regular Basis

In addition to these areas, there was not enough time for participants to come together in agreement on several other topics. These unresolved issues include complaints from beneficiaries about Medicare Part D; complaints from non-Medicare beneficiaries; the potential role for Alternative Dispute Resolution; the role of the Medicare Ombudsman; requirements and protections for provider confidentiality and beneficiary anonymity; how medical malpractice lawsuits might interact with the complaint process; and the costs of implementing a new complaint process.

IV.  Next Steps

The Center for Medicare Advocacy will continue to advance the work of the Quality Review Conference in a variety of ways.  These will include the following:

1. Publish this report and conference proceedings in a designated section of the Center for Medicare Advocacy’s website.

2. Prepare a “Beneficiary Quality of Care Complaint Systems” series for the Center’s weekly electronic publication, the “Weekly Alert.” This series will highlight the core elements of the complaint model identified at the Conference and described above. The Center’s “Weekly Alerts” reach a cross-section of the elder rights, health care, and media community, including legislative staff, health policy researchers, Medicare agency staff, academics and researchers, beneficiary advocates, Medicare beneficiaries, and the press.

3. Work with CMS staff to (a) expand its approach to the beneficiary quality of care complaint process to include exploratory models using medical boards and state licensing agencies, at least on a demonstration project bases, to test efficacy and efficiency; and (b) to embrace a set of initiatives to provide more Medicare beneficiary education about the current Medicare beneficiary quality of care complaint process.

4. Work with AHQA pending any movement of the complaint process, to improve their education and outreach efforts toward beneficiaries.

5. Seek funding for a Public Policy legislative “roundtable” targeting Congressional staff to alert members and staff to the issues raised at the conference, highlighting the beneficiary complaint model separate from the functions of the QIO as a viable legislative goal.