QIOs offer cost savings, quality, but will they last?
QIOs offer cost savings, quality, but will they last?
Lobbying, education used to publicize their role
While many hospital officials tout quality improvement organizations (QIOs) as a boon to their jobs, others believe they should go the way of the Edsel.
Last year, during its deliberations over Medicaid and Medicare, some members of Congress called for an end to quality improvement organizations (QIOs), formerly called peer review organizations and almost succeeded. This year, the American Medical Peer Review Association (AMPRA) in Washington, DC, is fighting back with lobbying and public education efforts that they hope will secure the place of QIOs in the future health care marketplace, AMPRA officials say.
As part of this effort, the trade association just changed its name from AMPRA to the American Health Quality Association (AHQA). Association members voted for the change at their annual meeting in Miami in September.
QIOs have been transformed over the last several years from cost-containment watchdogs to quality health care advocates. (See article on new role, Hospital Peer Review, October 1996, pp. 129-132.) Yet that transformation may not have been enough QIOs now must reinvent themselves and prove their worth to the federal government, the largest purchaser of health care, say health care attorneys and lobbyists.
"There has been some tinkering with [QIOs] in the most recent health insurance portability act, and their role is being re-evaluated," says Alice Gosfield, JD, principal with Gosfield & Associates in Philadelphia. "Sure, their future is in jeopardy. Will they go [completely] away? I don’t think so. There’s nothing else in the system that does their role."
The role of the QIO has been revised dramatically since 1983, when they were created to monitor costs and quality, notes Lisa Weiss, associate executive vice president of the AHQA.
"Through the years, there became increasing concerns for quality with premature discharges and readmissions, and the QIOs reoriented toward more quality oversight than cost concerns," she says.
In addition, QIOs have shifted their approach to reviewing cases from an emphasis on individual Medicare cases to examining patterns of care and population analyses, Weiss says.
But more changes might be needed such as shifting the sanctioning power of QIOs onto another agency, notes Gosfield.
Could someone else do the job?
What other agency could take on that sanctioning authority is debatable. Some AHQA officials speculate that as the population ages and more senior citizens move into managed care, the work of QIOs could be undercut by the National Committee for Quality Assurance (NCQA) in Washington, DC. the NCQA accredits managed care organizations.
But NCQA officials say they will never take on the role of QIOs. "NCQA programs take place at the health plan level and that’s not what the QIOs are doing. Their work happens at the provider level," says NCQA spokesman Barry Scholl. NCQA’s functions might expand as more HMOs that treat Medicare patients apply for NCQA accreditation, but the agency’s fundamental role will essentially stay the same, he says.
Nonetheless, the AHQA is not chancing a repeat of last year’s Congress. Concerns about whether QIOs would survive Medicare reform erupted last year when some in Congress questioned the appropriate role for QIOs and whether QIOs even had a role in quality oversight as the nation’s population moved toward a managed care market, says Weiss. The question has yet to be settled and the AHQA is sending the word out that QIOs play an important role across all health care plans.
"It is absolutely safe to say that there are those in the competitive medical marketplace who question the value of an independent external evaluation," Weiss says. "That said, I do believe and I am hopeful that we have an opportunity to better educate and inform folks in the coming year about the value of our work."
The work of QIOs can be complex and difficult for the public at large and some members of Congress to understand compared to the report cards generated by the NCQA or the inspection reports generated by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. So, the AHQA is beefing up its education efforts. "Things like accreditation and report cards are more readily understood but they are not the only markers of quality," Weiss notes.
Exhibiting QIO successes
The AHQA is spreading the word about the worth of QIOs by showcasing some QIO projects in both fee-for-service and managed care settings. "We’re talking to lawmakers, the media, providers, purchasers and consumers," she says.
The AHQAis publicly touting such projects as the national cardiovascular care project undertaken by the Healthcare Quality Improvement Program that looked at the records of a quarter of a million heart attack victims. Researchers found that while it is generally agreed in the medical community that aspirin reduces the risk of a subsequent heart attack, only half of the hospitals in the country administer aspirin within the prescribed time frames. "If we work with hospitals and health plans to change their processes, we have the opportunity to promote reduction of subsequent heart attacks," she says.
QIOs also can play a critical role in the future by translating science into practical medicine, Weiss notes. "When the message is understood, and when health plans have experience with us, they’ll understand our importance," Weiss says.
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