Quality Improvement in Medicare


Quality problems can be found in all types of health care delivery systems, regardless of payer. Poor quality in service delivery wastes resources, and can result in reduced function and even loss of life. A body of literature indicates that there is no relationship between spending and quality; geographic areas in which Medicare spending is greater do not always have better care outcomes.

CMS is ultimately responsible for ensuring that all Medicare providers meet high quality of care standards. These include nursing homes, home health agencies, hospitals, physicians and other health care providers and professionals, and end-stage renal disease providers. CMS quality strategies include:

  • establishing and enforcing quality standards for providers,
  • providing technical assistance through Quality Improvement Organizations (QIOs),
  • promoting collaborations and partnerships focused on improving quality,
  • supporting or directly providing consumer assistance and information about quality,
  • expanding the use of patient-reported measures in demonstrations and quality-improvement projects.
  • publishing information in support of accountability and public disclosure,
  • structuring payment and coverage to improve care, and
  • rewarding better performance.

CMS executes on these strategies in large part by managing quality improvement initiatives through partnerships with stakeholders, by identifying priority clinical areas, by adopting or developing performance measures, and by collecting, analyzing, and publishing data and comparative reports.

For traditional Medicare, CMS fulfills its responsibility directly and through contracts with organizations that monitor, survey, inspect, and review the provision of Medicare services. Quality contractors include state survey and certification units and independent accrediting bodies. The QIOs collect and analyze data on patterns of care and outcomes to help physicians and other providers improve the quality of beneficiaries’ care.

Quality Improvement in Medicare: Policy

Funding and quality improvement and oversight

In this policy: Federal

Congress should invest in the infrastructure of CMS to meet its responsibilities for quality oversight and improvement. CMS should develop and maintain adequate data systems to assess the quality of care in the traditional Medicare program.

CMS should:

  • continue to develop and implement measures for important clinical areas, cross-cutting issues (such as complications and care coordination), patient experience and engagement, patient-reported outcomes, and episodes of care that span care settings;
  • ensure that quality-improvement programs regularly evaluate whether there are improvements in outcomes and related processes—participating providers and practitioners should be required to implement patient-safety programs;
  • hold payment contractors, state survey agencies, independent accrediting bodies, and QIOs accountable for quality reviews and inspections;
  • address beneficiary complaints and pursue national clinical projects to measure access to and timeliness of care, and the appropriateness of setting, treatment, and discharge;
  • continue to offer information to help beneficiaries and others assess efficiency, continuity, and coordination of care;
  • take action against providers or practitioners when necessary to protect beneficiaries from substandard care; and
  • continue partnerships with other agencies to promote improvements in beneficiary care and well-being.