As administrator of Medicare, CMS uses several approaches to ensure that plans provide high-quality care and that this care is regularly assessed and improved. These approaches include setting conditions of participation, providing technical assistance through the QIO Program, and expanding public reporting initiatives. CMS also ties payments to quality improvement, encourages the adoption of health information technology, and promotes the creation and use of information about the effectiveness of health care technologies and treatment interventions.
Medicare requires MA plans to have ongoing quality improvement programs. These must include a chronic-care improvement program. In addition, each MA plan must collect and report data on quality measures, as specified by CMS. To facilitate data collection, plans are required to have a health information system that enables them to collect, analyze, and integrate the data necessary to implement quality improvement activities.
In addition, the ACA contains several payment provisions designed to encourage high performance by MA plans. (See this chapter’s section Health Care Coverage: Medicare—Medicare Advantage: Payments, Cost-Sharing, and Rebates.)
Medicare Advantage: Quality Improvement and Accountability: Policy
Given the financial incentives integral to the operation of risk-based private health plans, the federal government should strictly monitor compliance with Medicare program requirements, including those on quality of care.
CMS should hold all Medicare plans accountable for sustained quality improvement, regardless of model type.
Congress should establish a level playing field in Medicare by requiring all health plans to collect and report similar information on performance, thus enabling valid comparisons among plans.
All plans must have the capacity to collect, analyze, and integrate data for purposes of public reporting, accountability, and quality improvement activities. The quality assurance/quality improvement system should have the capacity to identify both exemplary and problematic patterns of health care (in the aggregate as well as for individual practitioners), and to take direct action, including referrals to enforcement agencies, in the event of seriously or persistently poor-quality care.
A Quality Improvement Organization (QIO) Programs
In addition to their own internal quality improvement activities, health plans should participate in quality improvement projects conducted by designated professional review entities that have no conflicts of interest, such as the QIO Program.
QIO Programs should:
- provide feedback on performance benchmarks that offer comparisons among plans, identify improvement opportunities, and allow plans to give individual practitioners feedback on their performance in relation to the benchmarks;
- educate practitioners about new practice guidelines and outcomes research;
- combine state-of-the-art technical expertise with a thorough knowledge of local medical practice to help each plan achieve the highest-quality care;
- advocate on behalf of Medicare beneficiaries in matters concerning quality of care;
- make data available to beneficiaries to promote informed health care choices;
- refer cases of seriously poor care to state licensing and regulatory authorities and/or federal authorities, as appropriate; and
- propose and facilitate implementation of systems to prevent medical error.
CMS should provide the public with provider-specific information about QIO findings concerning the performance of MA contractors.
AARP supports efforts to evaluate and improve oversight procedures to ensure that quality assurance programs, including the QIO review system, are effective.
Deeming by private accrediting organizations (PAOs)
Health plans that have achieved accreditation from PAOs should not be subject to redundant review by CMS, as long as the agency has judged the PAO’s standards to be comparable to the required federal standards for participating health plans.
When CMS authorizes a PAO to deem a health plan compliant with one or more of the state’s requirements, CMS must ensure that:
- it retains full authority to enforce all regulatory requirements (whether or not it relies on the PAO’s information, processes, or standards) and to initiate enforcement actions based on the results of a PAO’s processes and standards;
- the use of or reliance on a PAO’s assessment is subject to full and open public comment;
- a PAO’s standards and measures are readily and publicly available at nominal or no cost;
- information about individuals who conduct reviews on behalf of PAOs is publicly disclosed, including those individuals’ qualifications and affiliations;
- PAO surveys are periodically validated;
- the results of the PAO review process are made public; and
- the PAO has no conflicts of interest with the entities it accredits and is independent from them.
Private accreditation should not be a condition of participation in Medicare.
Compliance with federal standards or deeming compliant by a PAO should not preclude the requirement for health plans to undergo external quality review by designated professional review entities.
Congress should establish an adequate staffing level within CMS and provide adequate funding to permit effective monitoring of MA organizations.