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Beyond QIO: Modeling a Medicare Beneficiary Complaint Process for Quality of Care
A working conference convened on January 19, 2007 in Washington, DC by the Center for Medicare Advocacy, Inc., supported by the Commonwealth Fund, a New York City-based private foundation, and AARP

Introduction

The Center for Medicare Advocacy, Inc., (the Center), convened a working conference in January 2007 that designed a model for resolving Medicare beneficiaries’ complaints about quality of care. Sponsored by the Commonwealth Fund, with assistance from AARP, the conference provided a forum for key stakeholders to discuss concerns and develop a blueprint for change.

Medicare beneficiaries and their advocates are concerned that this current process for resolving beneficiary complaints about quality of care has not been effective in providing fair and timely resolution of complaints. Concerns about the process include an inadequate resolution of beneficiary complaints about poor quality, a lack of information about proper care protocols, and the failure to provide expedited review of denials of care.

The Center’s conference was triggered in part by the national Institute of Medicine’s (IoM) comprehensive study in 2006 of Medicare’s current beneficiary quality of care complaint process.  The IoM and others had on many occasions called for a beneficiary-focused complaint review process. The current process, operated under a contract with Quality Improvement Organizations (QIOs) has been found to be primarily provider-focused, assisting providers in quality improvement activities, rather than beneficiary-focused.  The IoM, as a result of its cumulative findings, recommended removing the function of performing quality of care investigations from the QIOs and allowing other entities to perform this work while QIOs continue to focus more specifically on assisting health care providers in quality improvement.

Background Papers

Prior to the conference, the Center commissioned three background papers to provide a framework for discussing the topics at hand. The first paper, written by senior attorneys from the Center for Medicare Advocacy, presented a brief history and an overview of the current Medicare beneficiary complaint process. The second paper, written from the perspective of a physician, examined and assessed the attributes of an ideal complaint process, regardless of the entity performing the review function. The third paper, written from an and academic legal perspective, explored possible alternative entities that might handle the complaint process function, including existing entities and a potential new entity. The papers were made available to the conference participants one week prior to the conference.  Participants were asked to read the papers as part of their preparation for the conference.

Participants

Forty-two invited experts from across the country participated in the day-long working conference (Agenda). Participants came from a diverse set of disciplines: beneficiary advocates, professors of law and public policy, attorneys, medical doctors, policy researchers, industry representatives, government officials, Congressional staff members, and representatives of various agencies that handle complaints.

Result

Our one day conference provided a remarkably full and productive discussion and preliminary blue print for a Medicare quality review system. The end result of the conference was a consensus model of an ideal Medicare beneficiary complaint review system. This work will continue as we work with the Centers for Medicare & Medicaid Services, the QIOs, and members of Congress to help move this important quality review discussion forward.

Please use the links below for more information about the conference. We have provided the commissioned background papers as well as other background materials and a narrative of the conference proceedings.

If you have any questions or comments regarding this conference, please e-mail achiplin@medicareadvocacy.org (remove spaces).

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