Medicare Advantage: Quality Improvement and Accountability

On this page: Medicare

Background

CMS uses several approaches to ensure plans provide high-quality care and that this care is regularly assessed and improved. These efforts include setting conditions of participation, providing technical assistance through Medicare’s Quality Improvement Organization 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 Medicare Advantage 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. 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 also this chapter’s section on Health Care Coverage: Medicare—Medicare Advantage: Payments, Cost-Sharing, and Rebates).

MEDICARE ADVANTAGE: QUALITY IMPROVEMENT AND ACCOUNTABILITY: Policy

Quality improvement and performance assessment

In this policy: Federal

All private health plans participating in Medicare should be engaged in ongoing quality-improvement programs. They should participate in quality-improvement activities with Medicare Quality Improvement Organizations (QIOs), as required by CMS, or with other QIOs.

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 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. This enables valid comparisons among plans.

All Medicare Advantage (MA) plans must demonstrate adequate performance in geriatrics and other aspects of care, as measured by their scores on valid and reliable quality indicators. These indicators should address a range of services, including preventive care and care for chronic illness, and should assess care coordination (including coordination across care settings) and other issues.

MA plans should contract with Advanced Practice Registered Nurses and other non-physician providers. Medicare Advantage (MA) plans should also routinely assess the performance of their practitioner and institutional contractors. This information should be available to participating providers and enrollees. Quality measures should be evidence-based and, wherever possible, should measure outcomes of care or processes that have a known relationship to outcomes.

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 Quality Improvement Organization (QIO) Program.

Quality Improvement Organization Programs

In this policy: Federal

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 federal authorities, as appropriate; and
  • propose and facilitate the implementation of systems to prevent medical error.

CMS should provide the public provider-specific information about QIO findings concerning the performance of MA contractors. Oversight procedures to ensure that quality assurance programs, including the QIO review system, should be evaluated for effectiveness and improvement.

Deeming by private accrediting organizations (PAOs)

In this policy: Federal

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.

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.

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 of them.
  • Private accreditation should not be a condition of participation in Medicare

Staffing CMS

In this policy: Federal

Congress should establish an adequate staffing level within CMS and provide sufficient funding to permit effective monitoring of MA organizations.