Quality Improvement in Medicare

Background

In many health care systems, the quality of care delivered to consumers has significant deficiencies. Preventable medical errors, unsafe care, and other health care quality shortfalls are costly. Despite an increase in public reporting of health providers’ performance on quality of care and patient safety, improvements have been slow. Without meaningful improvements, patients will continue to experience preventable hospitalization, worse health, and even loss of life. A body of evidence indicates that higher spending does not always translate into higher quality. And higher quality care does not necessarily mean costs must be higher. For example, geographic areas where Medicare spending is higher do not always have better care outcomes. 

The Centers for Medicare & Medicaid Services (CMS) is ultimately responsible for ensuring that all Medicare providers and clinicians participating in Medicare meet high quality-of-care standards. Providers include nursing homes, home health agencies, hospitals, hospice providers, and end-stage renal disease providers. Clinicians include physicians, nurses, and other health care professionals. CMS employs several quality strategies to meet that responsibility. 

These include: 

  • establishing and enforcing quality standards, such as publishing information to support accountability; 
  • 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, such as through public reporting; and 
  • expanding the use of quality measures that are meaningful to consumers and families in demonstrations and quality improvement projects. 

CMS executes these strategies primarily by managing quality improvement initiatives through partnerships with stakeholders, identifying priority clinical areas, adopting or developing performance measures, and 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. In addition, CMS incents providers to improve quality care by linking payment to performance measures on quality in value-based programs. 

QUALITY IMPROVEMENT IN MEDICARE: Policy

QUALITY IMPROVEMENT IN MEDICARE: Policy

Quality oversight and improvement

Congress should provide sufficient funding for the Centers for Medicare & Medicaid Services (CMS) to meet its responsibilities for quality oversight and improvement. 

CMS should develop and maintain adequate data systems to assess quality of care in the Traditional Medicare program. 

Additionally, 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 Quality Improvement Organizations 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.